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INDIGESTION,  BILIOUSNESS 


AND 


GOUT  m  ITS  PROTEAN  ASPECTS 


Part  I. 


liiMgc.^tioii  aiiir  ^ilioiisitc^'^ 


I 


BY 


J.  MILNER  FOTHERGILL,  M.D. 

JIEMBER    OF    THE    ROYAL    COLLEGE    OF    PHYSICLA.NS     OF    LONDON  ; 

SENIOR   ASSISTANT     PHYSICIAN    TO     THE     CITY    OF    LONDON    HOSPITAL    FOR     DISE.\SES 

OF     THE     CHEST     (VICTORIA     PARk)  ; 

LATE     ASSISTANT     PHYSICIAN     TO     THE     WEST     LONDON     HOSPITAL  ; 

ASSOCIATE     FELLO\V     OF     THE     COLLEGE     OF     PHYSICIANS     OF     PHILADELPHIA. 


"  What  is  one  man's  meat  is  another  man's  poison," 


NEW   YORK 
WILLIAM    WOOD    AXD    COMPAXY 

1881 


"The  accursed  hag,  dyspepsia,  had  got  me  bitted  and  bridled, 

and  was  ever  striving  to  make  my  living  waking  day  a  thing  of 

ghastly  nightmares." 

Tom  Carltle. 

"  The  yellow  gall  that  in  your  bosom  floats 
Engenders  all  these  melancholy  thoughts." 

Dryden. 

"  "What  doth  ensue. 
But  moody  and  dull  melancholy, 
(Kinsman  to  grim  and  comfortless  despair  ; ) 
And  at  her  heels  a  huge  infectious  troop 
Of  pale  distemperatures,  and  foes  to  life." 

Shakespeake. 


TO 


ANDEEW  CLAEK,  M.D.,  F.K.C.R, 

m  RECOGNITION   OP  HIS  ACUMEN   AND   KNOWLEDGE 

AS  A  PHYSICIAN  AND   A  THERAPEUTIST, 

THIS  WORK 

IS     DEDICATED 

BY 


®lje  2lutl)ox\ 


PEEFACE. 


The  study  of  clironic  disease  has  compelled  the  writer  to 
pay  minute  attention  to  the  subject  of  assimilation  and  its 
distui'bances. 

Eesearch  in  the  dead-house,  even  when  aided  by  the 
microscojDe,  can  never  supply  more  than  the  anatomical" 
factors  of  disease.  It  is  impotent  to  instruct  us  as  to  dis- 
tui'bance  of  function.  Physiology — an  acquaintance  with 
function  in  health,  alone  can  guide  us  to  a  knowledge  of 
disordered  function. 

The  following  book  is  wi'itten  fi'om  a  physiological  stand- 
point. 

The  history  of  normal  digestion  precedes  and  introduces 
the  subject  of  indigestion;  first  in  the  alimentary  canal, 
then,  secondly,  in  the  Kver.  By  such  study  the  manage- 
ment of  indigestion,  in  its  various  forms,  becomes  intel- 
Hgible.  Chaos  "without  form  and  void"  thus  becomes 
*'  dry  land  and  waters." 

The  disturbances  of  the  digestion  are  terriblv  on  the  in- 


vi  PREFACE. 


crease  in  the  present  clay ;  and  a  chapter  is  ajDpended  on 
"  The  Failure  of  the  Digestive  Organs  at  the  Present 
Time." 

For  a  contribution  to  this  subject,  as  well  as  other 
favours,  I  here  acknowledge  my  indebtedness  to  Duncan 
Bulkley,  M.D.,  of  New  York. 

For  aid  in  revising  the  proof-sheets  I  have  to  express 
my  thanks  to  David  X  Johnson,  Esq.,  M.B. 

23  Somerset  Street,  Portman  Square,  W. 
June  21st,  1881. 


co:ntekts. 

CHAPTEE  I 

PAGE 

Inteoduction 1 

CHAPTER  n. 

Natural  Digestion — Starch — Albuminoids — Fat  .         .       7 

CHAPTER  m. 
Pediary  Indigestion .21 

CHAPTER  IV. 

Suitable  Forms   of  Food — ^Artietclu:.  Digestive  Fer- 
ments  .         .         .  ■       .        .        .         .        .         .41 

CHx\PTER  V. 

Tissue  Nutrition 70 

CHAPTER  YI. 

Secondary    Indigestion — Neurosal — Reflex — Cardiac 

— ToxiEMic    ........     85 

CHAPTER  YH. 

Indigestion  as  an  Intercurrent  Affection  .         .  .126 

CHAPTER  Vm. 
Diet  and  Drink  . 136 


viii  CONTENTS. 

CHAPTER  IX. 

PAGE 

The  Functions  of  the  Livee       .         .         .         ;         .  148 

CHAPTER  X. 

The   Phenomena    of    Liver    Distuebance — Biliousness  167 

CHAPTER  XI. 

Phenomena  of  Liver  Disturbance   {Continued) — Liver 

Indigestion  ........  203 

CHAPTER  Xn. 

The  Treatment  of  Liver  Disturbance — Medicinal  and 

Dietetic       ........  249 

APPENDIX. 

The  Failure  of  the  Digestive  Organs  at  the  Present 

Time     .         . 290 


ON 

INDIGESTION  AND  BILIOUSNESS. 


CHAPTER  I. 

INTR  OD  UC  TION. 


Theee  are  man}'-  ailments,  many  disturbances  of  health, 
which  embitter  our  existence,  and  limit  our  power  of 
labour,  that  are  not  illumined  by  any  side-light  from  the 
dead-house.  They  are  essentially  the  maladies  of  the 
living'  ! 

It  is  not  disputed  that  in  certain  cases  changes  are  found 
in  the  dead-house,  enabling  the  cases  to  be  classed  as 
chronic  gastritis,  gastric  ulcer,  gastric  cancer,  or  gastric 
dilatation  ;  but  then,  these  are  the  ultimate  changes  at 
the  end  of  the  case.  Before  these  pathological  conditions 
have  been  developed,  there  has  been  a  long  preceding 
history  of  functional  disturbance;  and  even  when  they  are 
fully  developed,  the  stomach  retains  some  of  its  functional 
power  until  the  last;  or  until  very  near  the  last.  Such 
mere  anatomical  division  of  the  maladies  of  the  stomach 
is  useful  diagnostically,  and  prognostically;  even  more  so 
in  the  dead-house;  but  for  all  purposes  of  rational  treat- 
ment such  division  is  as  sterile  as  a  Vestal  virgin. 

To  be  of  practical  avail  to  the  patient,  the  stomach  must 
be  looked  on  from  the  standpoint  of  its  physiological  func- 


INTR  OB  UCTIOK  [chap.  i. 


tion  ;  which  is  not  abolished  by  the  particular  form  of  the 
disease.  In  all  those  myriads  of  cases  where  there  is  no 
gross  disease,  but  where  there  is  only  decided  dyspej^sia, 
any  classification  founded  on  pathological  changes  is  pow- 
erless to  help  us. 

Nor  are  we  correct  in  thinking  that  the  greatest  activity 
of  the  digestive  act,  is  to  be  found  in  the  stomach;  really, 
the  seat  of  greatest  activity  is  beyond  the  pyloric  ring,  in 
the  duodenum.  The  stomach  is  specially  the  seat  of  the 
digestion  of  albuminoids  in  an  acid  medium;  consequently 
the  morbid  changes  in  the  coats  of  the  stomach  are  not  the 
anatomical  substrata  of  all  disordered  function.  In  certain 
morbid  conditions  of  the  stomach,  the  mucous  coat  is  found 
diseased,  and  the  gastric  follicles  more  or  less  mutilated; 
but  what  would  this  tell  us  even  if  we  could  see  it  with  the 
eye  in  life  ?  It  would  demonstrate  the  necessity  for  en- 
couraging other  parts  of  the  digestive  sj^stem  than  the 
stomach  !  How  this  can  be  done,  will  be  shown  further 
on.  We  will  never  understand  digestion,  its  disturbances, 
and  how  to  meet  them,  by  poring  over  the  morbid  changes 
found  in  the  post-mortem  room  ;  even  when  aided  by  the 
microscope.  We  might  as  well  attempt  to  study  the  con- 
struction of  a  building  from  the  examination  of  it  in  ruin, 
and  by  minute  inspection  of  the  material  of  which  it  con- 
sisted. It  is  this  study  of  the  digestive  canal  after  life 
has  fled,  which  has  led  us  astray  from  the  real  study  of 
the  digestion  as  a  physiological  process  ;  how  it  comes  to 
be  deranged,  or  defective;  and  how  to  remedy  the  different 
disorders,  according  to  their  nature.  If  indigestion  were 
merely  a  deficiency  of  gastric  juice  due  to  disease  of  the 


CHAP.  I.]  IJSrTRODUCTIOy. 


walls  of  the  stomach,  its  treatment  would  be  rendered  very 
simple;  it  would  consist  in  giving  after  a  meal  so  much 
gastric  juice  derived  from  our  omnivorous  congener — the 
pig.  In  many  ca-ses,  doubtless,  this  is  enough  to  achieve 
Avhat  is  required;  but  this  is  not  the  whole,  nor  even  the 
main  part  of  the  rational  treatment  of  the  various  forms  o£ 
indigestion. 

Starch,  albuminoids,  and  fats;  each  of  these  has  its  own 
digestion,  its  own  portion  of  the  digestive  act;  which  must 
be  allowed  for  in  our  diagnosis,  and  in  the  selection  of  our 
remedial  measures.  The  treatment  of  indio;-estion  is  like 
the  fitting  of  a  suit;  there  are  the  three  component  parts 
of  the  suit — coat,  waist-coat,  and  trousers — to  be  seen  to. 
Two  may  fit;  but  the  third  does  not.  So  in  dyspepsia! 
Or  the  whole  may  be  badly  made,  or  ill-fitting.  The 
treatment  of  a  complex  malady,  is  like  the  making  of  a 
suit;  it  has  got  to  fit  the  individual  exactly.  Some  per- 
sons can  go  into  a  ready-made  shop,  and  buy  an  article- 
which  may  fit  very  fairly.  So  some  dyspeptics  only  re- 
quire pepsin  wine  for  their  cure.  But  this  is  not  the  rule; 
rather  is  it  the  exception.  Some  people  are  "bad  to  fit," 
in  tailor's  phrase;  and  tailors  differ  in  their  capacity. 
Some  people  are  not  "  easy  to  treat;  "  and  perhaps  all 
medical  men  are  not  alike  in  their  capacity.  Then  again, 
there  are  some  persons,  whom  even  very  competent  tailors 
cannot  fit;  only  one  tailor  can  manage  to  fit  them.  So 
there  are  a  proportion  of  persons  who  find  out  that  one 
medical  man  alone  can  prescribe  satisfactorily  for  them. 
With  tailors  and  doctors  alike  this  last  class,  fortunately 


4  JNTRODUCTION.  [chap.  i. 

a  very  small  one,  really  is  unpopular;  nor  is  there  any 
difficulty  in  conceiving  that  this  should  be  so. 

Then  again,  "biliousness,"  is  connected  with  disturbance 
of  the  digestive  process  in  the  liver;  a  matter  we  now  do 
know  something  about.  Until  recently,  yea  very  recently, 
we  really  did  know  nothing,  or  little  more  than  nothing  of 
the  function  of  this  huge  viscus.  But  lately,  thanks  to 
such  physiologists  as  the  late  Claude  Bernard,  Ludwig, 
as  Pavy,  and  Lauder  Brunton,  in  our  own  country;  our 
knowledge  has  of  late  made  giant  strides;  and  enlarged 
physiological  knowledge  has  led  the  way  and  broken  a 
path  for  a  rational  comprehension  and  treatment  of  the 
disturbances  of  the  liver.  The  chemical  composition  of 
the  bile-acids  tells  of  their  albuminoid  origin;  and  speaks 
with  no  indistinct  utterance  of  the  dietetic  management  of 
biliousness,  as  well  as  the  remedial  measures  to  be  em- 
ployed. 

The  chemical  composition  of  the  urine  solids  has  long 
years  ago  cleared  up  the  genealogy  of  gout;  but  we  recog- 
nise nevertheless,  that  gout  does  not  take  its  genesis  solely 
in  port-wine  and  gluttony.  Certainly  these  two  can,  in  the 
course  of  time,  provoke  gout,  if  sufficiently  persisted  in; 
even  in  the  healthiest  systems. 

Consequently  it  is  only  in  acquaintance  with  the  digestiv^e 
act,  and  the  disturbances  thereof,  first  intelligently  compre- 
hended, and  then  carefully  reasoned  upon  in  the  consider- 
ation of  assimilation  as  a  physiological  process,  that  we 
can  lay  the  foundation  of  a  rational  comprehension  of  the 
maladies — indigestion,  biliousness,  and  gout;  and  of  a 
treatment  which  is  successful,  except  by  a  lucky  guess. 


CHAP.  I.]  INTRODUCTION. 


But  lucky  guesses  do  not  run  thirteen  to  the  dozen.  Sys- 
tematic study,  leading  to  the  fuhiess  of  knowledge,  may  be 
a  laborious,  toilsome  way  of  acquiring  the  requisite  and 
desired  skill  ;  but  it  is  infinitely  surer,  as  a  rule,  and  more 
to  be  relied  upon,  than  those  flashes  of  inspiration  whose 
occasional  occurrence  is  not  denied  ;  but  whose  appearance 
cannot  be  calculated  upon  with  any  approach  to  certainty. 
Sap  and  mine  is  a  slow  but  sure  way  of  gaining  a  fort- 
ress ;  escalade  may  carry  it  by  storm,  but  it  is  notably  a 
hazardous  measure,  often  ending  in  failure,  sometimes  in 
grave  disaster. 

It  is  the  systematic  study  of  assimilation,  as  a  normal 
process,  and,  by  its  light,  mal-assimilation,  or  the  derange- 
ment thereof,  which  alone  can  enable  us  to  grapple  suc- 
cessfully with  maladies  which  are  the  bane  of  many  an 
existence  ;  which  usually  do  not  kill  directly,  but  which 
often  induce  consequential  changes  incompatible  with  the 
continuance  of  life.  The  albuminuria  which  heralds  the 
advent  of  the  final  change  in  old  gouty  kidneys,  is  but  the 
outcome  of  a  morbid  process  which  has  been  established 
for  years.  It  tells  of  the  end  of  the  case  ;  but  directly, 
it  throws  no  ray  of  light  upon  the  origin  of  these  morbid 
modifications  of  nutrition,  in  which  the  gouty  kidney  takes 
its  origin.  It  is  but  the  thunder  of  the  storm  ;  not  the 
electric  and  atmospheric  disturbances  which  bring  the 
thunder-storm  about.  To  understand  the  thunder-cloud 
we  do  not  confine  ourselves  to  observations  of  the  light- 
ning and  the  thunder  ;  we  go  further  back  into  the  genesis 
of  the  storm,  and  strive  to  comprehend  the  forces  which 
brought  it  about.     In  practice,  it  is  not  enough  to  test 


INTR  OD  UGTION.  [chap.  i. 


for  albumen,  or  examine  the  excreted  urine  solids  ;  it  is 
necessary  to  examine  the  digestive  processes  themselves, 
in  order  to  comprehend  the  malady  properly. 

In  order  then,  to  rationally  understand  the  nature  of 
indigestion,  biliousness,  and  gout,  we  must  commence  with 
a  clear  comprehension  of  the  digestive  act  in  health.  After 
that,  and  after  that  only,  we  may  hope  to  form  some  fair 
conception  of  its  disturbances. 


CHAPTER  II. 

NATURAL  DIGESTION. 
STAUGR.  —ALBUMINOIDS.  -  FA  T. 

It  may  be  well  to  first  take  a  bird's-eye  view  of  the  diges- 
tive act  ;  and  then,  after  that,  to  examine  each  part  piece- 
meal and  minutely.  By  this  means  the  reader  will  be 
enabled  to  grasp  the  subject  as  a  whole  ;  and  then  to  be- 
come familiar  with  each  section  of  the  whole. 

Our  knowledo-e  of  the  dio-estive  act,  as  said  in  the  In- 
troduction,  is  very  recent  ;  consequently  medical  teaching, 
until  the  last  decade,  had  little  to  say  on  the  matter.  Now 
physiology  has  acquired  articulate  speech  ;  and  can  talk 
sufiiciently  well  to  tell  us  much,  of  the  greatest  importance, 
on  subjects  which  interest  the  medical  practitioner  in 
almost  every  case  which  comes  under  his  notice  in  his 
every  day  round  of  professional  duty — much  that  adds 
most  materially  to  his  power  to  be  of  service  to  his  suffer- 
ing patients. 

The  subject  has  received  a  distinct  stimulus  by  the  de- 
livery of  the  Lumleian  Lectures  before  the  Royal  College 
of  Physicians,  last  year  (1880)  by  Dr.  William  Roberts, 
F.R.S.,  of  Manchester.  To  this  able  physician  and  his 
lucid  lectures  on  "The  Digestive  Ferments,"  and  "Arti- 
ficial Digestion,"  I  owe  much  for  further  information  on  a 
subject  which  has  long  interested  me  in  the  treatment  of 
chronic  disease.  I  shall  avail  myself  (by  his  permission, 
most  generously  and  gracefully  granted)  of  his  lectures  in 


8  NATURAL  DIGESTION.  [chap.  n. 

these  pages  very  fully  ;  nor  will  it  be  possible,  I  fear,  by 
the  mechanism  of  inverted  commas,  always  to  indicate 
every  piece  of  indebtedness  ;  especially  when  the  subject 
does  not  permit  of  verbatim  quotation.  By  the  study  of 
the  action  of  ferments  out  of  the  body,  much  has  been 
learnt  of  their  action  within  the  living  organism. 

A  "ferment"  is  a  body  which  works  changes  in  other 
substances,  altering  their  chemical  constitution  somewhat. 
Thus  yeast  is  a  ferment  used  in  the  making  of  bread.  In 
the  saliva  we  find  a  ferment  ;  in  the  gastric  juice  another 
ferment  ;  in  the  pancreatic  secretion  a  third — the  most 
complete  of  all. 

Now  let  us  consider  the  digestive  act  in  outline. 

First,  the  starch  of  our  food  is  acted  upon  by  the  saliva, 
which  converts  it  into  sugar  ;  as  soluble  sugar  in  the 
stomach,  it  is  absorbed  into  the  blood.  Then  the  albu- 
minoid constituents  of  our  food  are  acted  upon  by  the 
stomach  in  two  ways.  By  the  movements  of  the  stomach, 
the  mechanical  disintegration  commenced'  by  mastication, 
is  completed  ;  and  the  food  is  reduced  to  minute  fragments, 
upon  which  the  gastric  juice  can  operate  successfully. 
Thus  muscular  fibre,  the  type  of  albuminoid  food,  is 
crushed  by  the  teeth,  and  then  rolled  over  in  the  stomach 
until  the  minute  fibres  fall  asunder.  So  disintegrated, 
each  fibre  can  be  acted  upon  by  the  solvent  juice,  and 
digested.  The  removal  of  a  portion  of  the  starch  as  solu- 
ble sugar,  leaves  the  albuminoids  more  freely  exposed  to 
the  action  of  the  gastric  juice. 

During  this  time  fat  has  undergone  no  change.  The 
saliva  does  not  exercise  any  influence  upon  fatty  matters  ; 


CH.\p.  n.]  NATURAL  DIGESTION.  9 

neitlier  does  the  gastric  juice.  But  when  the  partially 
digested  food  passes  the  pyloric  ring,  then  intestinal  di- 
gestion commences ;  and  the  activity  of  the  digestive  act 
reaches  its  heis-ht. 

The  saliva  ferment  is  only  operative  in  an  alkaline  me- 
dium; consequently,  when  the  stomach,  or  rather  its  con- 
tents, becomes  acid  in  the  digestive  act,  the  digestion  of 
starch  ceases.  When  the  acid  contents  pass  the  pyloric 
rino^,  thev  meet  with  the  alkaline  bile-salts,  which  at 
once  arrest  the  action  of  the  gastric  juice,  which  is  only 
operative  in  the  presence  of  an  acid.  But  the  scene  only 
chancres;  not  the  act.  In  this  alkaline  medium  the  secretion 
of  the  pancreas  comes  into  play.  This  complex  secretion 
continues  the  digestion  of  the  albuminoids  in  an  alkaline 
medium;  the  conversion  of  starch  into  sugar  is  once  more 
in  progress,  and  the  fat  is  emulsionized.  We  see  a  totally 
new  process  instituted.  Hitherto,  fat  has  been  untouched 
bv  the  dio-estive  act.  Now  it  is  emulsionized,  reduced  to 
the  tiniest  of  particles,  which  are  taken  up  by  the  villi  of 
the  intestine.  Each  microscopic  villus  may  be  seen  crammed 
with  fat  or-lobules  some  time  after  each  meal. 

In  the  duodenal  or  intestinal  digestion,  the  starch  con- 
verted into  sugar  finds  its  way  into  the  intestinal  veins  ; 
so  do  the  digested  albuminoids ;  while  the  fat  is  taken  up 
by  the  villi,  the  terminal  ends  of  the  lacteals.  The  non- 
digested  materials  pass  on  to  form  the  faeces. 

"In  the  fasces  there  are  to  be  found,  in  the  first  place, 

the  indio^estible  and  indio-ested  constituents  of  the  meals, 

shreds  of  elastic  tissue,  much  cellulose  from  vegetables, 

and  some  connective  tissue  from  animal  food,  fragments 

1* 


10  NATURAL  DIGESTION.  [chap.  n. 

of  disintegrated  muscular  fibre,  fat  cells,  and  more  unfre- 
quently  undigested  starch-corpuscles.  The  amount  of  each 
must  vary  very  largely,  according  to  the  nature  of  the  food, 
and  the  digestive  powers,  temporary  or  permanent,  of  the 
individual.  In  the  second  place,  to  these  must  be  added 
substances  not  introduced  as  food,  but  arising  as  part  of,  or 
as  products  of,  the  digestive  secretions  "  (Michael  Foster). 
We  see  in  the  fjBces  the  remnants  of  a  feast.  The  uneat- 
able gristle,  the  bones,  fragments  of  meat  and  bread — the 
debris  which  remain,  and  have  to  be  cleared  away.  The 
rest  disappears,  carried  away  by  the  guests.  So  all  the 
nutrient  part  of  our  food,  or  most  of  it,  is  carried  away 
in  the  digestive  act ;  the  oifal  only  remains. 

Such  then  is  a  bird's  eye  view  of  the  digestive  act.  We 
now  can  profitably  examine  each  step  in  it  in  detail;  bit 
by  bit.  We  can  understand  how  "  the  nature  of  the  food," 
and  "  the  digestive  powers,  temporary  or  permanent,  of  the 
individual"  influence  the  process,  and  its  results:  see  how 
the  diet  can  be  modified  with  advantage  to  meet  the  powers 
of  the  individual:  how  improvement  in  the  digestive  powers 
of  the  individual  can  be  made  operative  in  securing  more 
perfect  digestion  of  the  food. 

Starch.  Starch  is  a  hydro-carbonaceous  material  found 
in  the  seeds  of  plants,  especially  the  cerealia,  in  pulm-pith 
as  sago,  as  tapioca  from  the  cassava,  and  as  arrowroot  from 
other  tubers,  or  as  potato  starch.  Its  chemical  formula  is 
Cj^H^qO^^.  It  is  the  material  upon  which  the  young  plant 
feeds  until  it  can  get  its  own  nutriment ;  except  as  sago. 

Like  animals,  vegetables  have  an  early  infant  period, 
when  the  food  is  found  for  them  by  their  parents.    Just  as 


CH.VP.  n.]  NATURAL  BIGESTION.  11 

the  chick  in  the  Qg^  lives  upon  the  material  stored  up 
within  the  shell ;  so  the  seed  lives  upon  the  starch  and  the 
fat,  also  stored  up  within  the  husk.  These  stores  of  ma- 
terial for  the  life  of  the  young  plant  are  garnered  for 
human  food.  The  digestion  of  starch  within  the  body  is 
allied  in  nature  to  that  process  by  which  the  infant  plant 
feeds  upon  the  starch  within  the  husk.  The  seed  undoes 
the  material  built  up  by  the  adult  parent  plant,  by  means 
of  a  ferment  contained  within  its  tissues.  In  maltinsr 
barley  the  ferment  within  the  grain  of  barley  changes  the 
starch  in  the  transformation  into  malt,  just  as  it  does  in 
germination  within  the  earth.  When  the  subject  of  arti- 
ficial digestion  is  considered,  w^e  shall  see  how  this  ferment 
of  barley,  diastase,  is  utilized  to  transform  the  starcliy 
matter  of  our  food,  vrhen  the  natural  digestion  of  starch  is 
defective.  The  plant  pulls  the  starch  granules  to  pieces 
and  renders  the  insoluble  starch  soluble  ;  and  that  is  just 
■what  happens  in  human  digestion. 

For  digestion  is  solution  ;  disintegration  precedes  solu- 
tion ;  the  insoluble  starch  must  be  converted  into  soluble 
grape  sugar,  to  pass  from  the  digestive  canal  into  the 
blood.  While  the  teeth  are  crushing  the  food,  and  the 
tongue  is  rolling  the  mass  over  and  over,  it  is  being  mixed 
and  inter-penetrated  with  saliva.  Saliva  contains  a  fer- 
ment identical  in  its  properties  with  the  diastase  of  barley. 
The  saliva  of  man  possesses  more  of  this  diastatic  power 
than  any  other  animal.  For  long  centuries  now  man  has 
cooked  the  starchy  material  of  his  food  ;  and  so  the  sali- 
vary glands  of  man  have  become  functionally  very  active. 
In  the  form  of  the  ground  cereals,  we  find  the  action  of  the 


12  NATURAL  DIGESTION.  [chap.  n. 

teeth  supplemented.  Disintegration  is  largely  performed 
for  us.  Then  by  cooking,  the  starch  granule  is  prepared 
by  the  action  of  the  digestive  ferment,  by  having  its  cap- 
sule ruptured.  When  bread,  a  biscuit,  or  pastry  is  chewed, 
the  saliva  is  mixed  with  the  farinaceous  particles,  and  the 
transformation  of  starch  into  grape-sugar  is  instituted. 
The  insoluble  starch  is  liquefied  by  hydration,  that  is  by 
the  addition  of  a  molecule  of  water,  into  dextrine  and 
grape-sugar. 

The  formulae  for  these  are  : 

Dextrine  C,  H,„  O, 
Grape-sugar  C,  H^,  O^. 

Food  could  not  be  stored  in  a  soluble  form  ;  it  would  bo 
washed  away.  So  the  digestive  act  is  the  dissolving  of  food, 
till,  in  fluid  form,  it  can  pass  through  the  walls  of  the  diges- 
tive canal  into  the  blood.  There  it  is  turned  back  de^ 
hydrated  by  the  removal  of  the  added  molecule  of  water, 
and  stored  up  in  the  body.  When  the  digested  starch  in 
the  form  of  dextrine,  the  soluble  or  grape-sugar,  is  taken 
into  the  blood  of  the  portal  vein,  and  reaches  the  liver,  it  is 
dehydrated  back  into  glycogen  or  "animal  starch."  As 
rapidly  as  the  starch  is  liquefied  into  soluble  sugar  it 
passes  through  the  walls  of  the  stomach  ;  and  so  does  not 
interfere  with  the  digestion  of  albuminoids  going  on  there- 
in. The  diastatic  action  can  only  go  on  in  an  alkaline  or 
neutral  medium  ;  as  soon  as  the  contents  of  the  stomach 
become  acid  the  diastatic  digestion  of  starch  is  arrested. 
What  starch  is  left  over  from  the  salivary  digestion,  re- 
mains unaffected  by  the  gastric  digestion.  When  the  food 
passes  the  pyloric  ring,  and  is  mixed  with  the  alkaline  bile. 


CHAP,  n.]  NATURAL  DIGESTION.  13 

then  the  digestion  of  starch  is  once  more  resumed  under 
the  influence  of  the  amylolytic  ferment  in  the  pancreatic 
secretion. 

Albumi7ioids.  From  the  albumen  in  the  eo^o-  the  tissues 
of  the  embryonic  chick  are  formed.  From  the  albumen  in 
the  seed  of  the  plant,  the  tissues  of  the  germinating  seed- 
ling are  fashioned.  Tissues  are  formed  from  albuminoids, 
with  some  auxiliary  assistance  from  hydrocarbons.  Liebig 
long  ago  pointed  out  how  the  presence  of  nitrogen  in  com- 
bination with  hydrogen  and  carbon,  interfered  with  their 
ready  union  with  oxygen.  Albumen  has  the  formula  ac- 
cording to  Hoppe-Seyler,  quoted  by  M.  Foster  : 

^•20.9     -tj-e.a     -'-^13.4     ^52.7      ^0.8 
to  23.5      to  7.3      to  16.5     to  54.5     to  2.0 

Containing  nitrogen,  albuminoids  do  not  readily  oxidize; 
and  thus  the  body  tissues  are  formed  of  albuminoid  mate- 
rials. The  hydrocarbons,  or  fuel  food  essentially,  burn  by 
oxidation  in  the  system,  while  the  tissues  themselves  do 
not  burn.  It  is  like  the  coal  burning  in  the  steam-engine, 
while  the  iron-work  does  not  burn.  Nevertheless  the  iron- 
Avork  wears  out  by  a  slower  process  of  oxidation,  known  as 
*'  rusting."  So  it  is  with  the  albuminoid  tissues  of  the  body; 
they  do  not  burn  properly,  but  they  slowly  oxidize,  or  rust 
TcS  they  wear  away. 

Albuminoids  are  not  affected  by  the  saliva;  the  gastric 
juice  is  their  solvent.  On  the  digestion  of  starch  the  gas- 
tric juice  exercises  no  effect,  except  to  arrest  the  action 
of  the  saliva  upon  it.  "  When  digestion  is  proceeding  com- 
fortably and  normally,  a  certain  interval  elapses  before  the 
acidity  of  the  stomach  becomes  considerable,  and  during 


U  NATURAL  DIGESTION.  [chap.  n. 

the  interval,  the  salivary  diastase  continues  active,  and  has 
time  to  accomplish  a  good  deal  of  work."  It  is  upon  albu- 
minoids that  "pepsin,"  the  gastric  ferment,  exercises  its  sole 
action.  The  gastric  juice  contains  pepsin  and  hydrochloric 
acid.  "In  one  important  respect  pepsin,  the  ferment  of 
gastric  juice,  differs  from  ptyalin,  the  ferment  of  saliva. 
Though  saliva  is  most  active  in  a  faintly  alkaline  medicine, 
there  seems  to  be  no  special  connection  between  the  fer- 
ment and  any  alkali.  In  gastric  juice,  however,  there  is 
a  strong  tie  between  the  acid  and  the  ferment,  so  strong 
that  some  writers  speak  of  pepsin  and  hydrochloric  acid 
as  forming  together  a  compound  pepto-hydrochloric  acid." 
(M.  Foster.)  Before  digestion  an  albuminoid  is  termed  a 
"proteid;"  the  digested  proteids  are  termed  "peptones." 
As  peptones,  albuminoids  readily  pass  through  the  walls  of 
the  digestive  canal  into  the  blood.  The  change  is  caused 
by  adding  a  molecule  of  water  ;  "  judging  from  the  ana- 
logy with  the  action  of  saliva  on  starch,  we  may  fairly 
suppose  that  the  process  is  at  the  bottom  one  of  hydra- 
tion" (M.  Foster).  The  solvent  action  of  the  gastric 
juice  is  greatly  aided  by  the  muscular  movements  of  the 
stomach;  as  the  contents  are  rolled  over  and  over  thereby, 
they  are  brought  into  immediate  contact  with  the  digestive 
pepsin  and  the  acid.  Muscular  fibres  fall  asunder,  and 
gradually  disappear  in  the  stomach  as  the  digestive  act 
progresses;  so  other  proteids  are  rendered  soluble  in  this 
acid  solvent  medium.  The  whole  of  the  proteids  are  not 
digested  in  the  stomach,  but  are  passed  through  the  pyloric 
ring,  when  it  relaxes  towards  the  termination  of  gastric 
digestion.    The  two  rings,  the  one  at  the  foot  of  the  gullet, 


CH.\p.  n.]  NATURAL  DIGESTION:  15 

the  cardiac  orifice,  as  well  as  the  pyloric  ring  at  the  intes- 
tinal outgoing  orifice  of  the  stomach,  are  contracted  dur- 
ing the  time  of  its  activity  ;  and  as  the  contents  become 
disintegrated,  the  pyloric  ring  relaxes.  The  food  has  fallen 
to  pieces  in  the  stomach,  such  of  it  as  will,  little  bits  of 
gristle  and  vegetable  fibre  being  left  eii  masse  y'  and  so  is 
prepared  for  further  intestinal  digestion.  The  fat  is  stored 
in  the  body  in  areolar  tissue,  in  the  connective  tissue,  or 
packing  material,  and  as  such  consists  of  fat  in  an  albu- 
minous envelope.  In  normal  digestion  that  envelope  is 
dissolved,  and  the  fat  set  free.  But  fat  itself  hitherto  has 
under2:one  no  chano-e  whatever.  "  On  fats  irastric  iuice  is 
powerless.  They  undergo  by  reason  of  it,  no  change  what- 
ever in  themselves  when  adipose  tissue  is  eaten,  all  that 
happens  is  that  the  proteid  and  gelatinigenous  envelopes  o£ 
the  fat-cells  are  dissolved,  and  the  fats  set  free  ;  the  far; 
itself  undergoes  no  change  except  the  very  slightest  emul- 
sion." At  times  the  liberation  of  fat  interferes  with  gas- 
tric digestion. 

Fat.  It  is  only  after  the  food  has  passed  the  pyloric  ring 
that  the  digestion  of  fat  commences.  Some  decomposition 
at  times  takes  place,  and  a  fatty  acid  is  formed,  which  irri- 
tates the  stomach,  and  constitutes  one  form  of  dyspepsia. 
''The  digestive  change  undergone  by  fatty  matters  in  the 
small  intestine,  consists  mainly  in  their  reduction  into  a 
state  of  emulsion,  or  division  into  infinitely  minute  particles. 
In  addition  to  this  purely  physical  change,  a  small  portion 
undergoes  a  chemical  change  whereby  the  glycerine  and 
fatty  acids  are  dissociated.  The  fatty  acids  thus  liberated 
then  combine  with  the  alkaline  bases  of  the  bile  and  pan- 


16  NATURAL  DIGESTION:  [chap.  n. 

creatic  juice,  and  form  soaps.  The  main  or  principal 
change  is  undoubtedly  an  emulsifying  process,  and  nearly 
all  the  fat  taken  up  by  the  lacteals  is  simply  in  a  state  of 
emulsion,  and  not  of  saponification."  Bile  exercises  some 
influence  upon  fats.  "  It  has  a  slight  but  only  slight 
emulsifying  power.  A  mixture  of  oil  and  bile  separate 
after  shaking,  less  rapidly  than  a  mixture  of  oil  and 
water  ;  this  action  is  probably  due  to  the  alkaline  nature 
of  bile.  Oil  passes  with  considerable  ease  through  a  filter- 
paper  kept  wet  with  a  solution  of  bile  salts  in  company 
with  one  kept  constantly  wet  with  distilled  water.  Bile 
therefore  must  be  said  to  have  a  slight  action  even  on  fats. 
It  is  probable,  however,  that  it  is  more  useful  when  com- 
bined with  pancreatic  juice  than  when  acting  by  itself  " 
(M.  Foster). 

A  fat  is  a  hydro-carbon,  containing  a  small  poportion  of 
oxygen.  It  is  formed  when  the  assimilation  of  hydro-car- 
bon is  in  excess  of  the  body  needs  ;  the  surplusage  is 
stored  as  fat  or  adipose  tissue.  This  reserve  is  consumed 
when  the  food  is  insufficient  in  supj^ly,  and  disappears  on 
starvation.  This  is  the  formula  of  stearin,  the  firmest  of 
the  fats. 

(C..H„OX 


C3  H,      )  °= 

The  others,  oleine  and  margarine,  are  much  the  same  che- 
mically. Oleine  is  the  most  fluid  and  then  comes  margarine. 
Speaking  broadly  the  digestibility  of  a  fat  is  in  proportion 
to  its  stiffness  when  cold.  The  best  cod-liver  oil  is  frozen 
at  a  low  temperature,  to  freeze  out  the  margarine  and 
stearine,  and  is  nearly  pure  oleine.     Cod-liver  oil  is  most 


CHAP,  n.]  NATURAL  DIGESTION.  17 

digestible  on  account  of  its  fluidity,  as  well  some  bile  in  it. 
Then  comes  the  fluid  fat  of  bacon,  butter,  and  then  cream, 
oils  and  animal  fats. 

Intestinal  digestion.  When  the  food,  now  known  as 
chyniej  rendered  fluid  or  semi-fluid  in  the  stomach,  passes 
the  pyloric  ring,  it  meets  the  alkaline  bile  and  becomes 
alkaline.  Then  the  digestion  of  pepsin  stops.  Just  as  the 
acid  gastric  juice  arrests  the  salivary  digestion  of  starch; 
so  the  alkaline  bile  kills  the  action  of  pepsine. 

To  this  alkaline  mass  is  poured  out  the  secretion  of  the 
pancreas.  This  is  a  most  j^otent  solvent  fluid.  It  con- 
tains (1),  a  diastase,  digesting  starch  ;  (2),  trypsin,  a  fer- 
ment digesting  proteids  in  an  alkaline  medium;  and  (3), 
an  emulsive  ferment  which  acts  upon  fats.  Like  the  gas- 
tric secretion  it  contains  a  ferment  which  curdles  milk — an 
action  necessary  to  the  digestion  of  milk.  Under  its  influ- 
ence the  dio[-estion  of  the  starch  left  in  the  stomach  after  the 
salivary  action  is  arrested,  is  resumed.  The  proteids  are 
converted  by  the  trypsin  into  peptones.  The  fat  is  emul- 
sionised  in  the  presence  of  bile.  The  solu-ble  sugar,  and 
the  soluble  peptones  pass  into  the  blood  of  the  portal  vein. 
The  fat  is  taken  up  by  the  lacteals  in  the  intestinal  villi 
and  carried  into  the  thoracic  duct.  The  waste  is  passed  on 
to  be  voided  :  beins:  still  acted  on  to  some  extent  by  the 
succu-s  entericus,  or  intestinal  juice. 

Such,  then,  is  tlie  digestive  act. 

After  being  made  soluble,  to  pass  through  the  walls  of 
the  digestive  canal,  sugar  and  peptones  are  turned  back  by 
dehydration,  into  starch  and  proteids.  They  have  been 
dissolved  so  as  to  pass  readily  through  organic  membranes; 


18  NATURAL  DIGESTION.  [chap.  n. 

now  they  are  to  be  stored  up,  so  they  are  changed  back; 
otherwise  they  would  escape  out  of  the  blood  as  easily  as 
they  got  into  it.  When  the  liver  is  unequal  to  dehydrating 
the  sugar  of  the  portal  vein  into  glycogen  as  rapidly  as  the 
sugar  is  formed,  the  sugar  passes  out  by  the  kidneys,  con- 
stituting glycosuria.  This  may  be  produced  in  any  one 
by  excess  of  sugar,  at  once.  When  the  disturbance  is- 
pronounced,  it  constitutes  "  Diabetes."  As  glycogen  or 
animal  starch,  the  amyloids  of  our  food,  are  stored  for  the 
needs  of  the  body,  and  given  off  as  required. 

The  after  history  of  peptones  is  very  interesting,  as  far 
as  it  is  known.  They  disappear  in  the  blood,  and  are  not 
found  in  it,  *'  neither  in  the  portal  blood,  nor  in  the  chyle, 
nor  in  the  general  blood  during  digestion,  is  there  any  ap- 
preciable quantity  of  peptones."  (M.Foster.)  In  a  recent 
article,  "  The  Practitioner,"  October  and  November,  1880, 
Dr.  Lauder  Brunton,  F.R.S.,  discusses  the  possibility  of 
peptones  escaping  the  dehydrating  process,  and  thinks 
"  that  the  liver,  to  some  extent  at  least,  serves  the  purpose 
of  preventing  any  peptones  from  getting  into  the  general 
circulation,  which  may  have  escaped  transformation  in  the 
portal  blood  before  meeting  it."  Indeed,  from  the  time 
the  peptones  disappear,  to  the  time  of  their  final  change  and 
appearance  as  excreta,  as  bile  acids  and  urine  solids,  we, 
as  yet,  do  not  know  their  history;  yet  it  is  what  we  would 
most  certainly  like  to  know.  From  the  albumen  in  the 
liquor  sanguinis  the  tissues  are  fed.  This  is  termed  "In- 
terstitial Nutrition."  Finally,  there  are  the  salts  of  the 
blood  to  be  considered.  We  do  not  know  of  any  digestion 
of  the  salts  of  the  body  beyond  mere  solution  of  them  in 
the  fluids.   Conditions  of  spanaemia  are  produced  from  their 


CHAP,  n.]  NATURAL  DTGESTIOy.  19 

deficiency,  either  from  the  food  not  containing  a  sufficiency 
of  them,  or  their  disappearance,  as  in  profuse  night-sweats. 
They  are  useful  in  digestion  somehow;  for  I  have  noticed 
again  and  again  at  the  City  of  London  Hosj^ital  for  Dis- 
eases of  the  Chest,  how  the  appetite  of  the  consumptive 
patient  improves  within  two  or  three  days  of  the  arrest  of 
severe  night-sweats.     Prof.  M.  Foster,  F.R.S.,  writes — 

"  The  efieots  of  salts  as  food.  All  food  contains,  be- 
sides the  potential  substances  which  we  have  just  studied, 
certain  saline  matters,  organic  and  inorganic,  having  in 
themselves  little  latent  energy,  but  yet  either  absolutely 
necessary,  or  highly  beneficial  to  the  body.  These  must 
have  important  functions  in  directing  the  metabolism  of 
the  body;  the  striking  distribution  of  them  in  the  tissues, 
the  preponderance  of  sodium  and  chlorides  in  blood-serum, 
and  of  potassium,  and  phosphates  in  the  red  corpuscles, 
for  instance,  must  have  some  meaning;  but  at  present  we 
are  in  the  dark  concerning  it.  The  element  phosphorus 
seems  no  less  important,  from  a  biological  point  of  view, 
than  carbon  or  nitrogen.  It  is  as  absolutely  essential  for 
the  srrowth  of  a  livins^  beino;  like  Penicillum  as  for  man 
himself.  We  find  it  probably  playing  an  important  j^art 
as  the  conspicuous  constituent  of  lecithin,  we  find  it  pecu- 
liarly associated  with  proteids,  apparently  in  the  form  of 
phosphates;  but  we  cannot  explain  its  role.  The  element 
sulphur,  again,  is  only  second  to  phosphorus,  and  we  find 
it  as  a  constituent  of  nearly  all  proteids ;  but  we  caimot 
tell  what  exactly  would  happen  to  the  economy,  if  all  the 
sulphur  of  the  food  were  withdrawn.  AVe  know  that  the 
various  saline  matters  are  essential  to  healtli;  that  when 
they  are  not  present  in  proper  proportions  nutrition  is  af- 


20  NATURAL  DIGESTION  [chap.  n. 

fected,  as  is  shown  by  certain  forms  of  scurvy  :  we  are 
aware  of  the  peculiar  dependence  of  proteid  qualities  on 
the  presence  of  salines  ;  but  beyond  this  we  know  very 
little." 

Lecithin  is  a  "complex  nitrog-enised  fat,  with  the  for- 
mula, C^^HgN.POg  occurs  widely  spread  throughout  the 
body.  Blood,  gall,  and  serous  fluids  contain  it  in  small 
quantities,  while  it  is  a  conspicuous  component  of  the 
brain,  nerves,  yolk  of  egg,  semen,  pus,  white  blood-cor- 
puscles, and  the  electrical  organs  of  the  ray  "  (M.  Foster). 

Iron  is  a  necessary  component  of  haemoglobin,  a  most 
complex  substance,  containing — O.^gH^NjgO^jS.^F.^. 

"  Haemoglobin  is  a  so-called  ozone  carrier  "  (M.  Foster). 
Here  is  a  very  complex  body  in  the  red  corpuscles,  upon 
which  depends  the  giving  off  of  carbonic  acid,  and  the 
taking  up  of  oxygen. 

Lecithin  is  a  phosphorized  fat  which  seems  to  be  the 
food  of  the  nervous  system  par  excellence. 

Where  these  infinitely  complex  bodies  are  formed  we  do 
not  know.  Yet  we  clinically  recognise  that  there  is  anre- 
mia  in  which  the  absence  of  iron  in  the  food  plays  a  part. 
It  seems  possible  that  the  imperfect  formation  of  "  lecithin  " 
may  be  the  cause  of  much  lack  of  nervous  energy  associated 
with  impaired  nutrition.  The  failure  of  the  assimilative 
processes  to  build  up  these  complex  bodies  may  co-exist  with 
power  to  form  the  ordinary  products  of  digestion.  We 
are  beginning  to  see,  albeit  "  through  a  glass  darkly,"  the 
clinical  value  of  a  good  knowledge  of  digestion,  in  its 
power  to  aid  us  in  the  treatment  of  many  maladies,  which 
take  their  origin  in  failure  of  the  digestive  processes. 


CHAPTER    ITT. 

PRIMARY  INDIGESTION. 

All  digestion,  then,  is  a  process  of  solution  for  which 
previous  disintegration  is  essential.  Indigestion  then  may 
be  due  to,  (1)  imperfect  disintegration;  and  (2)  defective 
solvent  power.  Of  course,  if  the  food  taken  be  of  an  un- 
suitable nature,  be  indigestible  in  itself,  then  indigestion 
follows;  for  which  the  digestive  processes  are  not  to  blame. 
Imperfect  disintegration.  This  is  mainly  due  to  insuffi- 
cient mastication.  Certainly,  when  uncooked  seeds  are 
eaten  the  disintegration  is  never  sufficient  ;  but  most  of 
our  food  requiring  thorough  disintegration,  is  prepared  for 
us  by  first  o^rindingr,  and  then  cookino-.  The  defect  lies 
either  in  the  bad  practice  of  eating  hurriedly;  or,  in  a 
growing  cause  of  indigestion,  bad  teeth.  As  to  the  practice 
of  eatino-  too  hastily  it  is  to  be  condemned  without  exten- 
uating  circumstances.  The  habit  of  eating  in  company 
and  chatting,  is  conducive  to  good  digestion,  by  prolong- 
ins:  the  meals;  and  allowino-  the  disintes-rating"  action  of 
mastication  to  go  on  efficiently.  It  is  not  merely  that  the 
effect  of  saliva  upon  starch  is  lost,  or  largely  so  (that 
might  be  made  up  for  and  compensated  by  the  later  diges- 
tion of  pancreatic  diastase),  but  the  food  is  insufficiently 
chewed;  and  is  therefore  swallowed  in  an  unprepared. state 
for  the  disintegrating  action  of  the  stomach.  To  grudge 
time  for  the  proper  mastication  of  food  is  as  irrational  as 
was  the  revolt  of  the  members  against  the  belly.     If  the 


22  PRIMARY  mDIGESTION.  [chap.  m. 

digestion  be  not  perfect,  then  the  rest  of  the  body  will 
suffer  from  want  of  pabulum.  The  food  should  be  slowly 
taken  and  thoroughly  chewed  :  if  the  teeth  will  permit. 
Even  when  a  glass  of  milk  is  swallowed,  or  a  cup  of  beef- 
tea,  containing  some  baked  flour,  it  is  all  the  better  for 
being  taken  slowly,  and  being  to  some  extent  mixed  with 
saliva  previous  to  being  swallowed.  When  farmers'  wives 
and  daughters  fed  calves  "  off  the  finger,"  so  that  they  got 
their  milk  slowly;  they  did  better  and  had  less  diarrhoea 
than  now  when  the  calves  are  allowed  to  take  their  milk 
greedily,  so  that  it  curdles  too  firmly  in  the  stomach.  The 
admixture  of  some  form  of  ground  farina  to  prevent  the 
formation  of  too  firm  a  curd  would  be  desirable;  if  the 
demands  of  modern  agricultural  life  can  no  longer  afford 
the  time  for  feeding  calves  "  off  the  finger."  Too  firm 
curdling  of  milk  is  a  common  cause  of  diarrhoea  both  in 
human  and  bovine  infants.  The  curd  is  indigestible,  so  it 
is  got  rid  of  as  readily  as  possible  by  ejection  from  the 
bowels.  In  all  cases  where  a  milk  diet  is  required,  this 
too  firm  curdling  should  be  looked  to;  it  is  the  equivalent 
of  imperfect  disintegration. 

Bad  teeth  are  a  fertile  cause  of  indigestion.  They  not 
only  forbid  perfect  mastication,  but  the  pain  of  mastication 
often  causes  the  food  to  be  bolted ;  even  when  the  individuals 
know  full  well  they  will  have  to  suffer  for  it.  The  present 
grave  increase  in  the  spread  of  dental  caries  is  matter  for 
the  most  serious  thought,  as  regards  the  next  and  ensuing 
generations.  If  this  sj^reads  as  it  is  doing  at  the  present 
time,  such  a  thing  as  a  natural  tooth  will  scarcely  ever  be 
seen.     As  soon  as  the  crowns  protrude  from  the  gum  they 


CHAP,  m.]  PRIMARY  INDIGESTION:  23 

will  require  the  care  of  the  dentist;  maybe  it  will  become 
necessary  to  nip  off  the  crowns  almost  as  soon  as  fully 
developed,  in  hopeless  despair  of  their  remaining  fairly 
sound. 

Bad  teeth  lead  to  impaired  digestion  in  two  ways,  (1)  they 
interfere  with  the  proper  admixture  of  saliva  with  the 
starchy  matters  of  the  food,  by  which  the  amylolytic  action 
of  salivary  diastase  is  lost  or  thrown  away;  and  (2)  by  im- 
perfect mastication  the  food  is  not  prepared  for  the  further 
disintegrating  action  of  the  stomach,  and  so  great  and 
abnormal  muscular  movements  of  that  viscus  are  required 
in  order  to  carry  on  the  disintegration  of  the  unchewed, 
or  imperfectly  chewed  food.  In  all  cases  of  indigestion 
then,  the  teeth  ought  to  be  critically  examined,  and  if  found 
defective  put  in  working  order;  after  which  the  trouble- 
some symptoms  may  pass  away  without  requiring  further 
medical  attention. 

Imperfect  disintegration  may  be  due  to  defective  action 
in  the  stomach.  There  the  atrophy  of  the  muscular  coat 
impairs  the  energy  of  the  movements  of  the  stomach;  as 
is  notably  seen  in  gastric  dilatation;  or  there  may  be  an 
abnormal  quantity  of  gastric  mucus  thrown  off,  in  which 
the  food  is  rolled  over  and  over,  until  a  thick  mucous  layer 
is  formed  which  most  effectually  resists  the  solvent  action 
of  the  gastric  juice,  so  that  the  action  of  the  salivary  dias- 
tase alone  goes  on,  and  the  food  is  passed  into  the  intes- 
tines in  no  way  advanced  by  gastric  digestion;  or  an  ulcer 
on  the  walls  of  the  stomach  may  arrest  the  muscular  move- 
ments of  this  viscus,  and  so  lead  to  impaired  disintegra- 
tion. In  all  these  cases  there  is  lessened  disintegrating 
power  in  the  stomach,  and  consequent  indigestion. 


24  PRIMARY  INDIGESTION^.  [chap.  m. 

Now  in  all  cases  of  indigestion  due  to  impaired  disin- 
tegrating action,  the  sole  remedy  is  to  modify  the  diet 
accordingly;  if  the  cause  of  the  impaired  disintegration 
be  not,  as  is  often  the  case,  removable.  Bolting  the  food 
may  be  remedied  ;  bad  teeth  may  be  supplemented  by  the 
skill  of  the  dentist;  imperfect  muscular  movements  in  the 
stomach  may  be  improved  by  the  administration  of  strych- 
nine. But  in  the  bulk  of  cases  the  treatment  lies  in  suita- 
ble food.  It  must  be  prepared  so  as  not  to  require 
disintegration.  In  mild  cases  it  is  sufficient  to  avoid 
pastry,  veal,  pork  and  other  things  which  are  not  easily 
disintegrated;  and  to  adopt  a  dietary  of  fish,  white  meat, 
milk  puddings,  and  stewed  fruit.  But  when  the  case  is 
one  of  gastric  catarrh,  ulcer,  dilatation,  or  cancer,  then  a 
strict  regimen  is  absolutely  necessary.  The  food  must  be 
in  fluid,  or  semi-fluid  form;  and  consist  of  such  materials 
as  require  neither  mastication  nor  the  exercise  of  much 
muscular  movement  in  the  stomach  ;  if  there  be  gastric 
catarrh  such  as  cannot  well  be  rolled  up  into  a  mass,  and 
covered  with  tenacious  mucus.  It  does  not  matter  what 
the  gastric  lesion,  the  digestive  act  is  the  same;  and  re- 
quires identical  management.  It  must  then  consist  of 
milk,  or  milk-gruel;  or  beef-tea,  or  mutton  broth  with  some 
baked  flour  added.  Such  then  briefly  is  the  management 
of  indigestion  due  to  imperfect  disintegration. 

Imperfect  solvent  action.  This  may  be  due  to  impairment 
in  the  saliva,  the  gastric  juice,  or  the  pancreatic  secretion. 
The  first  will  give  us  impaired  digestion  of  all  amyloid 
materials;  the  second  impaired  digestion  of  albuminoids; 
while  the  third  will  render  the  assimilation  of  fat  imperfect. 


CHAP,  m.]  PRIMARY  IJ^DIGESTIOX  25 

Deficiency  in  the  two  first  may  be  met  by  increasing  the 
activity  of  the  last  by  appropriate  measures.  But  defi- 
ciency of  fat-digestion  by  impaired  pancreatic  secretion 
cannot  be  compensated.  In  each  case  before  us,  it  is 
necessary  to  arrive  at  clear  views  as  to  what  it  is  we  wish 
to  remedy.  It  will  not  be  found  either  successful,  or  satis- 
factory to  prescribe  at  a  venture  either  medicine  or  arti- 
ficial digestive  agents,  in  a  hap-hazard  way.  To  give  bit- 
ters, hydrochloric  acid,  or  even  pepsin  wine,  when  it  is  the 
digestion  of  starch  and  fat  which  is  defective.  Nor  prepa- 
rations of  malt  diastase  when  it  is  the  digestion  of  albu- 
minoids which  is  impaired.  There  must  be  a  precision  in 
diagnosis  preceding  the  therapeutic  efforts,  guiding  and 
giving  aim  to  them,  for  the  latter  to  be  successful.  Pre- 
cision in  diaof'nosis  as  to  anatomical  chanore  has  been 
insisted  upon  usque  ad  nausemn,  considering  the  barren- 
ness of  results  attained  thereby.  But  precision  in  diag- 
nosis from  observation  of  physiological  function,  and  its 
disturbances,  has  yet  to  be  attained  ;  but  when  attained 
it  will  be  most  fertile  in  result. 

For  the  stimulation  of  the  salivary  glands  we  possess 
few  agents,  little  if  ever  resorted  to  for  the  purpose  of 
stimulating  the  salivary  glands.  The  chief  of  these  are 
mercury,  jaborandi,  and  pellitory.  Some  persons  chew 
ginger,  or  cinchona  bark;  but  such  measures  are  of  com- 
paratively little  service,  contrasted  with  the  resort  to 
vegetable  diastase  to  supplement  the  digestion  of  starch 
by  the  salivary  diastase. 

This  matter  will  receive  attention  in  the  next  chapter, 
devoted  to  the  consideration  of  the  Artificial  Digestive 
Ferments. 


26  PRIMARY  INDIGESTION.  [chap.  m. 

For  the  stimulation  of  the  gastric  secretion  we  possess 
several  agents.     There   are  a  number  of   articles  of   our 

o 

pharmacopoeia  which  increase  the  flow  of  gastric  juice. 
Among  them  are  agents  which  produce  severe  inflamma- 
tory symptoms  in  the  stomach  if  taken  in  larger  quantity, 
of  which  arsenic  is  the  type.  Alcohol  possesses  the  same 
power.  In  small  doses  both  these  agents  produce  a  flow 
of  blood  to  the  lining  membrane  of  the  stomach,  which  in- 
creases the  flow  of  juice.  When  empty  the  mucous  coat 
of  the  stomach  is  pale  and  bloodless.  When  food  is  taken 
it  becomes  red,  turgid  with  blood,  and  bedewed  with  secre- 
tion exuding  from  the  orifices  of  the  gastric  tubules.  Con- 
sequently the  glass  of  sherry,  or  even  gin  and  bitters,  is 
not  out  of  place,  or  out  of  time,  in  all  cases.  Where  it  is 
undesirable  to  resort  to  alcoholic  stimulants  the  old-fash- 
ioned dinner-pill  of  ipecacuanha,  cinchona,  and  aloes  and 
mvrrh  pill  is  indicated.  Ipecacuanha  in  small  doses  ex- 
cites the  mucous  membrane  of  the  stomach;  in  larger  doses 
it  excites  vomiting.  Further,  it  is  a  powerful  stimulant 
to  the  liver.  Consequently  it  is  indicated  as  a  constituent 
of  primary  importance  in  the  dinner-pill.  Then  there  are 
bitters  of  world-wide  reputation  both  to  whip  the  appe- 
tite, and  to  increase  the  digestive  power  of  the  stomach. 
Rino-er  has  found  that  the  contact  of  an  alkali  to  the 
lining  membrane  of  the  stomach  induces  a  subsequent 
flow  of  gastric  juice  if  taken  before  a  meal.  By  the  judi- 
cious fitting  of  such  measures  to  each  case,  good  results 
may  often  be  obtained  without  further  measures  being 
required.  These  other  measures  are  the  utilizing  of  the 
gastric  secretion  of  our  omnivorous  congener  the  pig,  to 
help  to  do  the  digestion  for  us. 


CHAP,  m.]  PRIMARY  INDIGFSTIOm  27 

So  long  as  the  stomach  was  supposed  to  be  the  sole,  or 
almost  sole  seat  of  the  digestive  act,  measures  intended  to 
act  upon  it  were  alone  sought  for,  and  enquired  after. 
But  when  physiological  research  discovered  that  the  sto- 
mach only  played  a  part,  a  comparatively  subordinate  part 
in  the  digestive  act,  other  means  were  searched  for,  and 
found;  viz.,  measures  which  stimulate  the  secretion  of  the 
pancreas  and  the  liver.  How  the  action  of  this  last  large 
viscus  has  so  long  remained  shrouded  in  Stygian  darkness, 
it  is  impossible  to  say.  Practical  medicine  has  gleaned  a 
scrap  or  two  of  empirical  lore  about  it.  But  science  was 
dumb,  or  scarcely  articulate,  until  this  sneer  was  justifi- 
able, "  it  w^as  taught  by  physiologists,  sixteen  hundred 
years  ago,  that  the  urine  was  formed  by  the  liver  and 
separated  by  the  kidneys;'  and  those  who  come  after  us 
may  judge  whether  the  nineteenth  century  have  made  any 
real  progress  in  this  matter  compared  with  Galen."  Cer- 
tainly it  was  not  till  late  in  the  nineteenth  century  that 
any  real  advance  was  made  in  our  knowledge  of  the  phys- 
iology of  the  liver  and  pancreas;  such  as  is  of  practical 
use  to  us  in  our  essays  to  aid,  or  remedy  disturbed  assimi- 
lation. 

For  the  stimulation  of  the  pancreas  we  possess  only  one 
agent  of  whose  properties  we  are  at  all  assured;  and  that 
is  sulphuric  aether.  Dr.  Balthazar  Foster,  of  Birmingham, 
first  used  aether  to  stimulate  the  pancreas  to  increased  se- 
cretion in  cases  where  cod-liver  oil,  taken  alone,  disagreed, 
or  was  not  assimilated.  The  addition  of  aether  led  to  satis- 
factory results.  Dr.  Foster's  expressions  of  opinion  and 
practice  led  to  a  Commission  being  formed  in  the  United 


28  PRIMARY  mDIGESTION.  [chap.  m. 

States  to  investigate  the  subject.  Their  results  corrobo- 
rated Dr.  Foster's  views. 

Instead,  however,  of  stimulating  the  pancreas  in  some 
cases,  it  is  more  convenient  to  employ  a  preparation  con- 
taining the  different  pancreatic  ferments,  as  the  Liquor 
Pancreaticus,  giving  it  according  to  the  directions  fur- 
nished in  the  next  chapter. 

For  the  stimulation  of  the  liver  we  can  use  a  variety  of 
ao-ents  whose  actions  have  been  much  elucidated  by  the 
work  of  Prof.  Rutherford  of  Edinburgh,  who  investigated 
the  action  of  drugs  upon  the  liver.  These  agents  are  ipe- 
cacuanha, iridin,  and  euonymin,  as  vegetables;  and  the 
sulphate  of  soda  as  a  saline  laxative  or  purgative,  accord- 
ing to  the  dose.  By  the  use  of  these  agents  the  liver  is 
stimulated;  a  fact  quite  corroborated  by  clinical  observa- 
tion. Sulphate  of  magnesia  is  a  stimulant  to  the  intes- 
tinal glands  and  a  purgative;  but  it  will  not  clean  the 
tongue  and  unload  the  liver  like  the  sulphate  of  soda.  It 
is  this  fact  which  led  me  to  .substitute  "  Sodas  Sulphat." 
for  "  Mag.  SuljDhat."  in  so  many  prescriptions  in  the 
second  edition  of  my  "  Practitioner's  Handbook  of  Treat- 
ment, or  the  Principles  of  Therapeutics"  (1880).  Espe- 
cially when  there  are  deposits  in  the  urine,  and  pale  stools, 
with  a  furred  tongue,  and  a  bad  taste  in  the  mouth  in  the 
morning,  is  the  use  of  these  hepatic  stimulants  to  be  re- 
sorted to:  and  the  results  so  attained  are  satisfactory 
when  a  proper  dietary  is  added  thereto.  As  to  the  efficacy 
of  hepatic  stimulants  there  can  be  no  more  doubt  than 
that  these  are  stimulants  to  other  glands.  Mercury  is 
especially  indicated  in  some  cases;  chiefly  when  the  blood 


CHAP,  m.]  PRIMARY  IKDIGESTIOK  29 

is  surcharged  with  nitroirenised  waste,  whether  bile  acids 
or  urine  solids. 

Some  co7icomita7its  of  Indigestion.  It  may  be  well  now 
to  consider  some  concomitant  states  which  require  atten- 
tion, before  proceeding  to  review  the  matter  of  the  inabil- 
ity to  digest  fats;  often  a  very  grave  affair,  especially 
when  iound  with  profuse  night  sweats. 

In  gastric  catarrh  not  only  must  the  food  be  fluid  or 
semi-fluid,  and  utterly  free  from  perceptible  particles,  such 
as  may  be  rolled  into  a  ball  and  enveloped  in  a  covering  or 
catarrhal  mucus;  but  means  must  be  used  to  check  the 
catarrh.  Compound  kino  powder  is  a  great  favourite  in 
the  treatment  of  gastric  catarrh;  the  pill  of  sulphate  of 
copper  and  opium  is  often  useful.  Other  combinations  of 
opium  and  astringents  may  be  used.  T.  King  Chambers 
Las  pointed  out  that  in  gastric  catarrh  these  combinations 
do  not  produce  constipation  to  the  extent  that  might  be 
anticipated;  their  astringent  action  apparently  being  spent 
upon  the  morbid  mucous  lining  of  the  stomach. 

In  gastric  ulcer  it  is  well  to  give  an  opiate  an  hour  before 
food  is  taken.  This  lessens  the  pain,  and  diminishes  the 
movements  of  the  stomach,  so  that  vomiting  is  prevented 
to  a  great  extent.  It  allows  the  food  to  pass  through  the 
stomach  into  the  duodenum,  especially  when  it  consists  of 
milk-gruel  already  partially  digested.  Bismuth  is  also 
very  useful. 

In  gastric  cancer  an  opiate  is  equally  indicated.  Both 
in  ulcer  and  in  cancer,  when  the  surface  is  raw,  the  acid 
of  the  gastric  juice  causes  acute  pain,  so  the  food  should 
be  "  sheathed  with  an  alkali." 


30  PRIMARY  INBIGESTIOm  [chap.  m. 

In  gastric  dilatation,  it  is  desirable  to  empty  the  stom- 
ach artificially  from  time  to  time,  and  then  wash  it  oat 
with  a  solution  of  the  sulphites.  The  diet  always  to  be 
most  carefully  attended  to  in  each  case. 

In  diarrhoea,  especially  when  it  comes  on  immediately 
after  food,  the  contents  of  the  small  intestine  are  swept 
along  too  rapidly  for  absorption  to  go  on  properly;  and 
therefore  the  system  is  badly  nourished.  Here  opium  and 
bismuth  are  especially  indicated,  together  with  a  strict 
milk  dietary.  Often  there  is  acidity,  especially  with  in- 
fants, and  then  lime  water,  prepared  chalk,  or  light  mag- 
nesia— some  or  other  of  the  fixed  alkalies,  should  be  added 
to  the  milk. 

Astringents  containing  tannin,  or  the  mineral  astrin- 
gents, as  sulphate  of  copper,  and  opium  are  indicated  in 
true  ordinary  diarrhoea.  Sometimes  larger  doses  are  re- 
quired than  those  in  ordinary  use.  AVhen  the  diarrhoea  is 
frequent,  teasing,  and  the  amount  passed  small  in  quantity 
and  no  relief  is  obtained,  then  it  is  well  to  give  a  full  dose 
of  castor  oil,  or  rhubarb.  If  it  persist  after  this  the  rec- 
tum should  be  explored,  for  a  mass  wdll  probably  be  found 
in  the  colon,  preventing  the  passage  of  solid  freces. 

In  constipation  it  is  well  to  give  a  pill  at  bedtime,  and  if 
necessary  a  saline  purgative  next  morning.  The  pill  may 
consist  of  Pil.  Al.  et  Myrrh.,  Pil.  CoL  Co.,  according  as  a 
mild,  or  a  more  powerful  laxative  is  required.  Then  next 
morning  a  dose  of  effervescing  citrate  of  magnesia,  or  a 
purgative  water,  or  some  black  draught;  or,  better  still, 
some  soda  sulphate  with  Rochelle  salts  in  a  bitter  infusion 
containing  a  carminative,  taken  warm.     A  morning  laxa- 


CHAP,  m.]  PRIMARY  INBIGESTIOK.  31 

live  taken  warm  acts  at  once,  more  promptly  (a  great 
matter  for  business  men),  and  more  efficiently.  At  other 
times  Trousseau's  plan  of  a  suppository  of  hardened  honey, 
or  soap  may  be  tried;  or  it  may  be  enough  to  resort  to  an 
enema.  In  very  severe  constipation  it  is  "well  to  give 
potent  cathartics,  scammony,  podophyllin,  or  gamboge  at 
night,  and  a  saline  purgative  in  the  morning.  But  the  case 
must  be  followed  up  actively,  and  the  constipation  relieved 
somehow;  else  the  indigestion  cannot  be  remedied.  (Dys- 
peptics with  confirmed  constipation  are  very  difficult  pa- 
tients to  manage,  and  require  a  medical  adviser  of  deter- 
mined will,  as  well  as  considerable  skill  in  the  wielding  of 
remedial  agents.) 

When  there  is  pruritics  ani  (itching  of  the  fundament) 
also  present,  then  hepatic  stimulants  are  required  for 
relief.  This  may  be  due,  however,  to  the  presence  of 
*'  Seat  AYorms,"  which  require  sharp  cathartics,  and  injec- 
tions of  infusion  of  quassia. 

Anal  fissures,  ulcers,  piles,  fistulae,  &c.,  require  treat- 
ment that  cannot  be  described  here. 

The  regulation  of  the  bowels  by  an  appropriate  dietary 
will  be  given  in  Chap.  YIII.  But  laxatives  are  commonly 
required  as  well  in  cases. 

At  othertimes  there  isgastric  irritability  to  be  dealt  with. 
Then  the  tongue,  our  only  index  of  the  state  of  the  intes- 
tinal canal,  is  raw^  and  denuded  of  epithelium,  either  in  a 
broad  furrow  up  the  middle,  or  over  the  surface  generally. 
When  this  condition  obtains,  whether  alone,  or  along  with 
pulmonary  consumption,  or  other  malady,  it  claims  our 
attention  exclusively;  at  least  all  other  matters  must  only 


32  PRIMARY  INDIGESTION.  [chap.  m. 

bo  subordinate.  This  imperativeness  is  too  commonly  not 
fully  recognized,  with  disastrous  results.  But  experience 
tells  that  it  must  be  the  chief  object  of  our  solicitude. 
'^  Needs  must  when  the  devil  drives,"  and  this  condition  of 
denuded,  or  but  partially  grown  epithelium  cannot  be  re- 
legated to  a  second  place  in  our  remedial  measures,  with 
due  regard  to  the  patient's  safety.  As  a  skilful  general 
changes  his  front  according  to  his  enemies'  tactics,  so  the 
wary  physician,  when  he  sees  this  change  coming  on, 
changes  his  line,  when  the  malady  puts  on  this  new  aspect. 
Bismuth  and  alkalies,  a  milk  diet,  with  the  alkaline  sheath; 
firmness,  patience,  and  perseverance,  are  all  required  to 
see  the  patient  safely  through  "  the  valley  of  the  shadow 
of  death;"  when  aphthae  appear  the  efforts  must  be  re- 
doubled. When  the  tongue  recovers  its  normal  aspect, 
and  the  epithelium  is  no  longer  half-grown,  but  quite  ma- 
tured, then  the  treatment  may  advance  to  mineral  acids; 
but  so  long  as  the  bareness  remains,  so  long  must  the 
treatment  be  directed,  if  not  exclusively,  still  mainly,  to 
the  state  of  the  lining  membrane  of  the  digestive  tract. 

Then  there  is  "  the  funded  tongue^''  where  there  is  a  perfect 
layer  of  debris  of  food  and  dead  epithelial  scales,  indicative 
of  the  state  of  the  lining  membrane  of  the  digestive  canal. 
Not  uncommonly  purgatives  have  been  taken  by  the  pa- 
tient, once  or  oftener,  to  remove  it.  If  mercury  have  been 
no  part  of  the  remedies  employed  no  effect  has  followed,  as 
regards  improvement  in  the  condition  of  the  tongue.  A. 
mercurial  will  usually  make  the  desired  alteration;  but 
not  always.  In  some  cases,  however,  the  relief  is  not  so 
readily  furnished;    and  the  mercurial  must   be  repeated, 


CHAP,  m.]  PRIMARY  INDIGESTION.  33 

and  a  mixture  containing  nitro-hydrochloric  acid  and  small 
doses  of  sulphate  of  soda,  is  requisite  for  a  week  or  even 
more,  before  the  digestive  organs  are  restored  to  their 
normal  working  condition. 

In  some  cases  the  tongue  looks  normal  till  placed  in  a 
side  light,  and  then  by  looking  across  the  tongue  a  brown 
shade  can  be  observed.  Here  the  same  line  of  treatment 
is  required;  and,  however  anaemic  the  patient  may  be,  it 
is  useless,  worse  than  useless  to  give  chalybeates:  for 
when  the  liver  is  disturbed,  iron  never  agrees. 

There  are  certain  states  of  the  digestive  organs  when  the 
patient  complains  that  the  sight  of  fat  produces  repugnance 
and  loathing;  but  where  there  are  no  decided  objective 
symptoms.  But  they  cannot  digest  fat,  at  least  in  its 
ordinary  forms.  Whether  it  is  the  fat  interferes  with  gastric 
diofestion,  and  is  intolerable  to  the  stomach;  or  there  is 
also  some  inability  to  digest  the  albuminous  capsule  of  the 
fat  granules  in  adipose  tissue;  or  what  the  particular  ob- 
jection is,  is  not  yet  known;  the  fact  remains  that  fat  is 
most  objectionable  to  them. 

What  to  do  with  these  cases  as  regards  their  dietetic 
management  will  be  given  in  the  next  chapter,  in  the 
section  devoted  to  the  practical  measures  to  be  adopted 
when  the  assimilation  of  fat  is  disturbed. 

It  is  clear  from  what  has  so  far  been  written  that  the  old 
impression  of  the  stomach  being  the  sole  seat  of  the  diges- 
tive act  must  be  abandoned  in  favour  of  views  more  sound, 
and  in  accordcince  with  the  teachings  of  modern  physio- 
logy; if  we  are  to  be  exact  in  our  treatment  of  the  disturb- 
ances of  the  assimilative  processes. 


34:  SYMPTOMS.  [chap.  m. 


SYMPTOMS. 

A  FEW  of  the  prominent  symptoms  produced  by  indigestion 
may  now  be  given  briefly.  One  of  the  frequent  outcomes 
of  indigestion  is  the  production  of  an  acrid  acid  in  the 
stomach.  This  seems  to  be  one  of  the  fatty  acids,  prob- 
ably butyric,  and  is  very  acrid  in  its  properties.  It  is 
usually  not  produced  early,  but  rather. late  on  in  the  diges- 
tive act.  It  causes  a  bitter  pungent  taste  felt  at  the  foot 
of  the  gullet.  This  sensation  is  termed  "  cardialgia  "  or 
"heart-burn."  Another  is  *' pyrosis  "  or  "  vrater-brash." 
This  consists  in  the  eructation  of  a  fluid  into  the  fauces, 
sometimes  acid,  sometimes  alkaline;  at  other  times  acrid, 
or  even  feeling  "  cold."  Certain  articles  of  food,  notably 
oatmeal,  are  apt  to  produce  it.  A  third  is  "  regurgitation  " 
of  the  food;  sometimes  sour,  sometimes  sweet.  With  some 
persons,  this  act,  analogous  to  "chewing  the  cud,"  is 
habitual;  a  certain  number  say  it  is  not  disagreeable  to 
them. 

Allied  to  this  is  the  "  eructation  of  wind  "  or  "  belching," 
to  many  persons  a  great  source  of  annoyance.  When 
highly-flavoured  articles  of  food  are  eaten,  the  taste  is 
often  very  pronounced  in  the  eructated  wind.  The  cock- 
ney phrase  for  this  is  an  expressive  one — their  food  "  re- 
peats," they  say.  "  Flatulency "  is  another  outcome  of 
disordered  digestion,  and  often  creates  a  most  uncom- 
fortable sense  of  distension.  Frequently  the  pressure  of 
this  elastic  gas  in  the  stomach  produces  "palpitation." 
Betwixt   the    heart   and   the    stomach    lies  the  thin   dia- 


cn.ip.  m.]  SYMPTOMS.  35 

pliragm  only  ;  and  gas  in  the  stomach,  or  transverse 
colon,  presses  upon  the  heart  and  interferes  with  its 
movements;  producing  either  "palpitation"  or  "inter- 
mittency  "  in  its  stroke,  as  the  case  may  be.  "  Vomit- 
ing "  is  not  very  common  except  in  acute  indigestion; 
and  gives  immediate  relief,  as  it  does  in  gastric  ulcer.  It  is 
most  frequent  in  "gastric  catarrh  "  in  the  morning;  es- 
pecially where  too  much  alcohol  has  been  taken  the 
previous  evening*.  In  acute  dyspepsia  it  is  the  natural 
form  of  attaining  relief.  It  is  often  followed  by  sharp 
diarrhoea,  sweeping  away  such  part  of  the  contents  of  the 
stomach  as  have  passed  into  the  intestinal  tube.  At  other 
times  "diarrhoea"  is  provoked  by  each  meal.  "Itching 
at  the  seat  "  is  found  in  other  cases,  and  it  is  a  most 
torturinof,  distressing-  affection.  ^Yhen  it  is  due  to  seat- 
worms  it  is  readily  amenable  to  treatment  in  most  in- 
stances; but  not  in  all. 

Then  there  is  "  pain "  at  the  pit  of  the  stomach. 
When  due  to  "gastric  ulcer"  it  is  provoked  as  soon  as 
the  stomach  has  become  acid,  and  is  aggravated  by  the 
muscular  movements  dragging  on  the  base  of  the  ulcer; 
thus  vomiting  gives  immediate  relief.  So  long  as  the 
stomach  is  at  rest,  and  in  its  alkaline  state  of  quiescence 
there  is  no  pain.  In  "  gastric  cancer  "  there  is  also  sharp 
pain  not  always  relieved  by  vomiting;  nor  alone  provoked 
by  food,  but  felt  at  other  times  at  first,  and  ultimately 
continuous' and  persistent.  Pain  is  commonh^  found  along 
with  other  evidences  of  indigestion,  and  may  occur  imme- 
diately after  a  meal;  or  at  a  later  period  when  the  contents 
of  the  stomach  are  passing  the  pyloric  ring;    when  felt  at 


36  SYMPTOMS.  [chap.  ni. 

this  time  it  is  duodenal.  ''  Na,usea,"  or  a  sense  of  sick- 
ness, is  a  very  common  symptom  either  fpund  along  with 
pain,  or  alone.  It  may  be  present  almost  habitually;  but 
be  accompanied  by  actual  vomiting  only  when  the  disturb- 
ance of  the  digestive  act  is  unusually  great. 

"  Constipation  "  is  a  common  concomitant  of  dyspepsia; 
not  rarely  its  exciting  cause.  So  long  as  constipation  is 
permitted  to  continue,  so  long  will  dyspepsia  persist.  By 
perseverance,  patience,  and  determination,  the  most  ob- 
stinate constipation  may  be  overcome.  Too  frequently, 
however,  the  jDatient  grows  indifferent,  or  tires  of  the  treat- 
ment, and  as  a  consequence  relapses  into  the  habitual 
condition.  It  is  the  bane  of  their  lives  to  many  persons; 
still  it  is  much  more  amenable  to  treatment  than  is  gener- 
»  ally  supposed. 

The  throat  often  feels  sore,  or  uncomfortable;  at  other 
times  there  is  a  tendency  to  "  hawk  up  phlegm,"  which 
gathers  on  the  fauces.  In  some  cases  there  is  a  turgid 
state  of  the  fauces,  little  dendritic  vascular  twigs  being 
very  visible.  Less  frequently,  there  are  "  purple-like  ele- 
vations of  the  mucous  membrane,"  at  times  even  "  folli- 
cular ulceration;  "  or  the  uvula  is  relaxed  and  elongated, 
tickling  the  throat  and  producing  troublesome  cough. 
"Aphthae"  are  not  usual  except  in  children,  or  adults 
the  subjects  of  severe  advanced  exhaustion. 

The  tongue  should  always  be  carefully  inspected.  Some- 
times it  is  "  swollen,"  "  relaxed,"  and  "  indented  with  the 
teeth;"  at  other  times  it  is  "  raw  "  or  '' irritable,"  being 
denuded  of  its  epithelium.  In  other  cases  it  is  "  foul  " 
or  "loaded;"   and  this  "fur"  may  be  yellow,  or  brown, 


CHAP,  in.]  SYMPTOMS.  37 

especially  when  the  liver  is  disordered.  Or  there  may  be 
a  "strawberry"  tong-ue:  sometimes  like  a  red  strawberry 
with  the  ])apilla3  like  the  red  seeds;  more  commonly  it 
resembles  a  white  strawberry,  the  tongue  being  generally 
white  with  red  papillne  protruding  through  the  fur,  closely 
resembling  the  red  seeds  upon  a  white  strawberry.  Less 
commonly  the  papilla3  are  enlarged,  looking  like  small  in- 
flamed warts;  these  are  the  large  papillae,  fifteen  to  twenty 
in  number,  near  the  root  of  the  tongue.  At  times  a  foul 
streak  is  seen  along  the  mesial  line  of  the  tong-ue,  the 
edges  being  very  clean;  at  other  times  this  is  reversed,  a 
clean  streak  running  up  the  middle  of  the  tongue.  Some- 
times one  side  of  the  tongue  is  fouler  than  the  other; 
here  there  is  a  local  cause.  "  Fissures  "  of  the  tongue  are 
not  rare;  most  commonly  associated  with  the  practice  of 
drinking  hot  fluids,  especially  tea.  "  Deep  sulci "  are 
usually  syphilitic,  especially  when  the  tongue  generally  is 
smooth  as  if  the  papillae  were  shaven  cleanly  off  with  a 
razor.  Such  a  sign  is  of  great  importance,  as  some  cases 
of  indigestion  have  been  incurable  till  an  anti-syphilitic 
treatment  has  been  adopted  for  some  other  ailment;  and 
then,  presto,  the  indigestion  has  disappeared. 

"  Psoriasis  "  is  also  significant.  There  seems  some  evi- 
dence that  the  stomach  is  sometimes  the  seat  of  analoofues 
to  skin  affections;  as  it  certainly  is  the  seat  of  an  erup- 
tion in  some  cases  of  small-pox. 

"  Skin  eruptions  "  are  very  frequently  linked  with  diges- 
tive disturbances,  and  only  curable  by  putting  the  diges- 
tive organs  in  order.  Eczema  with  pruritus  of  the  geni- 
tals, or  anus,  is  always  associated  with  dyspepsia  in  some 
part  of  the  digestive  tract. 


38  SYMPTOMS.  [chap.  m. 

In  soine  cases  tliere  is  a  "taste  in  the  mouth,"  especially 
a  hot  burning  taste  on  awaking  in  the  morning.  This  is 
due  to  some  abnormal  products  of  the -later  part  of  the 
digestive  act,  and  is  often  a  troublesome  symptom.  In 
certain  cases  there  is  a  sour  taste  in  the  mouth,  less  com- 
monly a  sweet  taste,  or  the  saliva  may  be  clammy  with 
a  sensation  of  heat  in  the  mouth;  this  is  commonly  found 
along  with  constipation. 

"  Headache "  is  a  very  common  outcome  of  dyspepsia. 
,  It  varies  in  character  from  a  dull  weight  to  acute  agony. 
It  may  be  confined  to  the  temples,  the  forehead,  or  the 
occiput;  or  it  may  be  general.  It  may  be  accompanied  by 
"swimming"  in  the  head,  or  "intolerance"  of  light  or 
of  sound.  At  times  the  slightest  sound  is  simply  unbear- 
able; in  other  cases  (comparative)  ease  can  only  be  secured 
bv  Ivino'  in  a  dark  room  like  the  Rev.  Mr.  Irwine's  sister 
Anne,  in  "Adam  Bede."  Miss  Kate  was  sponging  the 
achino-  head  with  fresh  vineorar  when  he  went  into  the 
room  so  darkened  by  blinds  and  curtains  that  Miss  Kate 
could  not  knit  at  the  best.  "  It  was  a  small  face,  that  of  the 
poor  sufferer;  perhaps  it  had  once  been  pretty,  but  now  it 
was  worn  and  sallow.  Miss  Kate  came  towards  her  brother 
and  whispered — *  Don't  speak  to  her;  she  can't  bear  to  be 
spoken  to  to-day.'  Anne's  eyes  were  closed,  and  her 
brow  contracted  as  if  from  intense  pain."  Miss  Anne 
Irwine's  headaches  were  those  of  indigestion  evidently; 
and  very  bad  headaches  they  were  !  They  belonged  to 
that  variety  which  comes  on  the  day  after  the  meal  which 
has  provoked  them;  where  there  are  some  noxious  pro- 
ducts of   late  digestion  poisoning   the  half-starved  brain. 


CH.iP.  m.]  SYMPT03LS.  39 

In  such  cases  the  duodenum  is  found  to  be  the  scat  of 
morbid  change,  when  the  patient  2')asses  into  the  dead- 
house.  In  most  cases  the  headache  accompanies  other 
evidences  of  gastric  disturbance,  and  is  felt  early,  or  after 
a  meal.  Tlie  face  is  often  flushed,  and  the  hands  and 
feet  are  cold.  In  many  cases  the  headache  is  distinctly 
that  of  aniemia, — the  blood  being  drawn  to  the  abdominal 
viscera  by  the  digestive  act.  There  is  often  a  sensation 
of  "  swimming  in  the  head  "  felt  along  with  the  pain,  or 
"dizziness."  The  pain  in  the  vertex  often  experienced  is 
symptomatic  of  cerebral  ansemia. 

More  distressing  than  the  actual  physical  pain,  is  the 
sense  of  misery  experienced  by  many.  The  mental  dis- 
comfort, the  sense  of  wretchedness,  of  utter  unfitness  for 
work,  and  inability  to  collect  the  thoughts,  is  to  many 
dyspeptics  their  greatest  trouble. 

The  brain  is  disabled  for  the  time,  no  matter  what  its 
capacity  under  favorable  circumstances;  and  the  sense 
of  intellectual  paralysis  is  very  distressing.  Here  there  is 
positive  toxaemia,  from  abnormal  products  of  digestion 
finding  their  way  into  the  blood  ;  as  well  as  an  insuffi- 
cient supply  of  blood  to  the  brain.  To  brain-workers  this 
is  a  great  drawback;  indeed,  the  dyspeptic  is  handicapped 
very  heavily  in  the  race  of  competition  to  gain  a  living,  or 
amass  a  fortune.  The  dyspeptic  can  earn  less,  and  must 
spend  more  on  (suitable)  food  than  others  do;  and  where 
the  income  is  a  small  one,  the  dyspeptic  is  really  to  be 
pitied.  Indigestion  cuts  down  the  individual  far  more 
than  is  generally  credited.  In  the  modern  keen  struggle 
for  existence,  the  dyspeptic  is  like  a  man  fighting  with 
one  hand  tied. 


40  SYMPTOMS.  [chap.  m. 

This  mental  attitude  of  gloom,  apprehension,  distrust, 
and  incapacity  intensifies  the  physical  discomfort,  and 
tends  to  cause  the  sufferer  to  have  misgivings  that  the 
malady  is  something  more  than  mere  indigestion.  A 
haunting  fear  that  the  brain  is  the  seat  of  disease  where 
there  is  headache,  the  heart  where  there  is  palpitation 
or  irregular  action,  tortures  the  unhappy  sufferer.  The 
remembrance  of  this  impression  hangs  like  a  dark  cloud 
over  the  intervals  of  comparative  health;  while  the  antici- 
pation of  another  attack  is  projected  like  a  shadow  thrown 
in  front  of  it,  indeed  "  coming  events  cast  their  shadows 
before."  When  there  is  great  pulsation  of  the  abdominal 
aorta  the  dyspeptic  is  worried  with  the  apprehension  that 
there  may  be  an  aneurysm  present.  There  is,  indeed,  a 
panphobia,  a  general  sense  of  dread,  of  impending  evil 
which  embitters  the  sufferer's  existence,  and  every  un- 
comfortable sensation  is  interpreted  as  an  indication  of 
structural  disease  somewhere.  The  physical  suffering  is 
aggravated  by  mental  misery,  compared  with  which  it  is 
as  nothing:  for  peace  of  mind  is  rendered  absolutely  im- 
possible to  the  unfortunate  dyspeptic;  he,  or  she  lives  with 
the  sword  of  Damocles  hanging  overhead. 


CHAPTER  W. 

SUITABLE  FORMS  OF  FOOD. 
ARTIFICIAL  DIGESTIVE  FERMENTS. 

Having  described  the  various  disturbances  of  the  dig-estive 
tract,  interfering  with  the  23roper  and  ordinary  assimilation 
of  the  main  constituents  of  our  dietary,  starch,  albuminoids, 
and  fat  ;  it  may  be  well  to  review  the  means  of  preparing" 
the  various  forms  of  our  food.  Starch  in  its  natural  state, 
raw  and  uncooked,  is  scarcely  digestible  by  man.  In  ani- 
mals, probably  starch  is  mostly  digested  by  the  pancreatic 
diastase.  But  in  man  starch  is  largely  digested  by  the 
salivary  diastase.  "  It  has  been  noted  that  the  saliva  of 
man  possesses  more  diastatic  power  than  that  of  almost 
any  other  animal.  Among-  the  herbivora,  which  are  such 
large  consumers  of  starch,  the  saliva  has  comparatively 
little  diastatic  power  ;  and  in  some,  as  the  horse,  it  is 
almost  altogether  wanting,  I  apprehend  that  this  is  due 
to  the  fact  that  man  alone  has  learnt  to  cook  his  starchy 
food,  and  that  the  diastatic  power  of  his  saliva  has  become 
developed  with  the  opportunity  for  its  exercise.  Diastatic 
power  would  be  thrown  away  in  the  saliva  of  the  horse, 
because  he  eats  his  food  in  the  raw  or  uncooked  state,  and 
saliva  is  almost  without  action  on  raw  starch."  This  is  a 
very  interesting  observation  by  Wm.  Roberts,  and  as  re- 
gards the  horse,  no  attempt  has  been  made  to  cook  his- 
food  for  him.  But  with  the  animals  the  farmer  wishes 
to  fatten  for  market,  especially  oxen,  the  cooking  of  their 


42  SUITABLE  FORMS   OF  FOOD.        [chap.  iv. 

food  is  regularly  performed  by  our  most  advanced  agri- 
culturist. Starch  is  prepared  by  cooking  cereals  previous 
to  their  being  given  to  cattle  ;  as  it  is  found  cheaper  to  so 
pre23are  the  starch  for  fatting  cattle,  than  to  leave  them 
to  do  the  whole  of  their  dio-estion  for  themselves.  The 
Lincolnshire  farmer  has  solved,  in  part  at  least,  the  prob- 
lem of  the  conversion  of  starch  into  sugar,  or  approaches 
thereto  ;  as  well  as  the  scientific  physiologist.  And  one  of 
the  most  instructive  conversations  on  the  means  of  prejDar- 
ing  starch  for  food,  I  everremember  listening  to,  was  down 
in  the  Fens  one  evening,  when  some  farmers  were  discuss- 
ing the  subject  of  the  cheapest  means  of  fattening  stock. 
It  was  soon  clearly  apparent  that  they  were  working  in 
precisely  the  same  direction  as  the  23hysiological  physician 
moves,  when  he  comes  to  diet  a  child  with  a  weak  digestion; 
with  this  difference — the  physician  desires  to  feed  the  child 
little  regardless  of  the  cost;  while  the  farmer's  aim  is  to 
produce  so  much  fat  at  the  least  cost.  When  inspecting 
the  measures  adopted  by  Collinson  Hall,  at  his  large  dairy 
farm  in  Essex,  my  attention  was  arrested  by  a  huge  heap 
in  one  of  the  rooms,  where  crushed  oats  and  partially 
malted  barley,  were  fermenting  the  starch  into  dextrine 
and  maltose. 

In  cooking  starch  the  granule  is  cracked,  and  the  starch 
largely  gelatinised,  so  that  the  salivary  diastase  readily 
liquefies  it,  and  converts  it  into  soluble  sugar.  During 
baking,  starch,  or  part  of  it,  is  undoubtedly  converted 
into  dextrine.  The  action  of  yeast  converts  part  of  the 
starch  into  sugar,  and  this  again  into  "  alcohol  and  car- 
bonic acid  gas  ;  the  latter,  in  its  efforts  to  escape  from  the 


CKAT.  i\\]        SUITABLE  F0E3IS   OF  FOOD.  43 

<loLigh  with  Avliicli  it  is  mixed,  distends  it,  forming  vesi- 
cular spaces  ill  its  interior,  and  so  causing  it  to  become 
porous  and  light.  Much  of  the  alcohol  is  dissipated  in 
the  process  of  baking  "  (A.  Hill  Hassall),  Consequently 
vre  see  that  intuitively  and  without  the  light  of  science, 
man  has  commenced  the  artificial  digestion  of  starch, 
when  only  a  savage,  and  long  before  the  dawn  of  his- 
tory. "\Ve  at  the  present  are  emerging  out  of  the  early 
darkness,  and  stepj^ing  forward  b}^  the  morning  light  on 
the  path  to  the  artificial  digestion  of  starch  ;  by  so  doing 
economising  the  body-energy  which  would  otherwise  be 
consumed  in  the  conversion  of  insoluble  starch  into  a 
soluble  saccharoid,  otherwise  diastatio  digestion.  Conse- 
quently farinaceous  materials  are  first  ground  and  then 
cooked  J  this  constitutes  the  first  part  of  the  digestive  act. 

Now  it  is  a  matter  of  no  little  importance  to  understand 
intelligently  how  cooking  may  affect  the  digestibility  of 
prepared  starch.  "When  farina  is  simply  boiled  or  baked 
with  milk,  the  preparation  is  at  once  simple  and  digestible, 
and  the  saliva  is  rapidly  mixed  therewith  in  the  mouth. 
But  when  eggs  are  added,  then  the  disintegration  in  the 
mouth  is  not  nearly  so  perfect,  and  much  more  chew- 
ing is  required  ;  because  the  coagulated  albumen  holds  the 
starch  granules  together.  Consequently  milk  puddings  for 
invalids  are  better  made  without  eggs. 

Then  again,  everybody,  medical  and  lay,  knows  how  in- 
digestible is  pastry  of  all  kinds.  When  the  farina  and 
fat  are  closely  mixed  together  in  the  act  of  "kneading 
the  dough,"  the  adhesive  property  of  the  gluten  of  flour 
is   somehow  so  increased,  that  the  act  of  mastication  is 


44  SUITABLE  FORMS   OF  FOOD.         [chap.  iv. 

rarely  equal  to  efficient  disintegration  in  those  whose 
digestion  is  feeble.  The  stomach  is  incited  to  active 
muscular  movements  to  continue  the  disintegration,  and 
acute  pain  is  experienced.  A  piece  of  pie-crust  is  rank 
poison  to  many  dyspeptics.  So  is  toasted  cheese,  which 
also  resists  the  disintegrating  action  of  the  dyspeptic's 
stomach  very  effectually.  Some  persons  cannot  eat  suet 
pudding,  as  ordinarily  made,  without  a  severe  penalty 
from  dyspepsia  :  but  if  the  cook  adds  to  the  flour  a  cer- 
tain quantity  of  bread-crumbs,  then  the  digestion  of  the 
pudding  is  painless.  Gluten  once  cooked  remains  non- 
adhesive  ;  so  the  bread-crumbs  cause  the  masses  of  pud- 
ding to  readily  fall  to  pieces  in  the  stomach.  Probably 
some  baked  flour  would  do  just  as  well,  if  added  to 
the  ordinary  flour.  Maize  flour  is  not  nearly  so  adhe- 
sive, as  its  albuminoids  are  not  in  the  form  of  tenacious 
gluten  ;  so  much  so,  that  without  some  wheaten  flour  it 
will  not  make  leavened  bread.  Consequently,  for  the 
preparation  of  puddings,  and  still  more  for  pastry  for  deli- 
cate children  and  dyspeptics,  it  would  be  well  to  add 
some  maize  flour  to  the  ordinary  flour.  In  precisely 
the  same  way  we  try  to  prevent  milk  forming  too  firm 
a  curd  in  the  stomach,  by  mixing  with  it  some  starch. 
The  presence  of  the  starch  granules  interferes  with  the 
solidity  of  the  curd,  and  causes  it  to  fall  to  pieces  readily 
in  the  stomach.  On  the  other  hand,  oysters  are  spoiled 
in  cooking.  "  Our  practice  in  regard  to  the  oyster  is 
exceptional,  and  furnishes  a  striking  example  of  the 
general  correctness  of  the  popular  judgment  on  dietetic 
questions.      The    oyster  is  almost  the  only   animal  sub- 


CHAP.  I^^]        SUITABLE  FORMS   OF  FOOD.  45 

stance  which  we  eat  habitually  and  by  preference,  in  the 
raw  or  uncooked  state;  and  it  is  interesting  to  know  that 
there  is  a  sound  physiological  reason  at  the  bottom  of 
this  preference.  The  fawn-coloured  mass  which  consti- 
tutes the  dainty  of  the  oyster  is  its  liver,  and  this  is 
little  less  than  a  mass  of  glycogen;  associated  with  the 
glycogen,  but  withheld  from  actual  contact  with  it  dur- 
ing life,  is  its  appropriate  digestive  ferment — the  hepatic 
diastase.  The  mere  crushing  of  the  dainty  between  the 
teeth  brings  these  two  bodies  together,  and  the  glycogen 
is  at  once  digested,  without  other  help,  by  its  own  diastase. 
The  oyster,  in  the  uncooked  state,  or  merely  warmed,  is, 
in  fact,  self-digestive.  But  the  advantage  of  this  provi- 
sion is  wholly  lost  by  cooking,  for  the  heat  employed  im- 
mediately destroys  the  associated  ferment,  and  a  cooked 
oyster  has  to  be  digested,  like  any  other  food,  by  the 
eater's  own  digestive  power."  This  graphic  description 
bv  Dr.  Roberts  tells  us  how  it  is  that  ovsters  au  naturel 
are  so  much  in  vogue  for  invalids,  as  they  deservedly  are. 
Also,  why  oysters  should  not  be  cooked  in  oyster  sauce, 
but  put  into  the  prepared  sauce  just  as  it  comes  to  table. 
AVhy,  as  King  Chambers  insists,  in  a  beef-steak  pudding, 
the  oysters  should  not  be  cooked,  but  a  flap  of  the  paste 
raised,  and  the  oysters  popped  in,  just  as  the  pudding  is 
served.  In  making  oyster  pates,  the  paste  is  cooked  in 
bread-crumbs,  which  is  then  taken  out  and  the  oysters 
put  in;  after  which,  the  pates  are  just  warmed,  and  no 
more,  and  then  brought  up  to  the  dinner  table.  The  idea 
that  long  cooking  increases  the  digestibility  of  food,  is  not 
always  correct. 


46  SUITABLE  FORMS  OF  FOOD.        [chap.  iv. 

But  "  cooking"  is  essentially  a  part  of  the  digestive  pro- 
cess, not  only  in  man,  but  in  some  domesticated  animals 
as  well.  The  products  vary  according  to  the  skill  of  the 
cook,  and  the  adjustment  of  the  process  to  what  physiolo- 
gical knowledge  tells  us  is  correct  and  sound.  When  the 
cook  makes  a  hash  of  meat  already  cooked,  instead  of 
making  the  gravy  first,  and  when  fully  prepared  then 
putting  in  the  slices  of  meat,  and  just  warming  them  before 
serving — the  only  way  by  which  a  hash  is  tolerable  to  a 
delicate  stomach — she  too  often  stews  it  well  in  the  gravy, 
believing  that  thereby  she  increases  its  digestibility.  But 
ask  dyspeptics  about  meat  so  cooked  a  second  time,  and 
their  tale  of  woe  is  most  instructive. 

Now  as  to  the. effects  of  cooking  upon  the  proteid  ele. 
ments  of  our  food.  "  It  is  this  well-established  fact,  tho 
easier  digestibility  of  loosely-aggregated  tissue,  that  has 
led  me  to  repudiate  raw  meat  in  the  diet  of  invalids. 
Cooking,  the  action  of  heat,  disassociates  organic  tissues, 
destroys  the  cohesion  of  muscular  fibres,  and  must,  there- 
fore, render  all  kinds  of  meat  easier  to  dissolve,  to  digest. 
To  give  meat  raw,  however  finely  chopped,  is  to  forego  all 
the  advantages  gained  by  judicious  cooking,  and  to  force 
on  the  digestive  organs  double  work.  Moreover,  raw, 
uncooked  meat  may  contain  the  ova  of  human  entozoa,  of 
the  various  species  of  tape-w^orms,  and  of  the  trichina" 
(James  Henry  Bennett,  "  Nutrition  in  Health  and  Dis- 
ease ").  Again,  Dr.  Roberts  writes:  "  With  regard  to  the 
staple  articles  of  our  food,  the  practice  of  cooking  it  before- 
hand is  universal.  In  the  case  of  farinaceous  articles, 
cooking  is  indispensable.     When  men  under  the  stress  of 


CHAP.  IV.]        SUITABLE  FORMS   OF  FOOD.  47 

circumstances  have  been  compelled  to  subsist  on  the  un- 
cooked grain  of  the  cereals,  they  have  soon  fallen  into  a 
state  of  inanition  and  disease.  By  the  process  of  cooking-^ 
starch  is  not  merely  liberated  from  its  protecting  enve- 
lopes, but  it  suffers  a  chemical  change,  by  which  it  is 
transformed  into  a  gelatinous  condition,  and  this  enor- 
mously facilitates  the  attack  of  the  diastatic  ferments.  A 
change  of  equal  importance  seems  to  be  induced  in  the 
proteid  matter  of  the  grain.  I  found  that  the  gluten  of 
wheat  was  incomparably  more  digestible,  by  both  artificial 
gastric  juice  and  by  pancreatic  extract,  in  the  cooked  than 
in  the  uncooked  state.  In  regard  to  flesh  meat  the  advan- 
tage of  cooking  consists  chiefly  in  its  effects  on  the  connec- 
tive-tissue, and  the  tendinous  and  aponeurotic  structures 
associated  with  muscular  fibre.  These  are  not  merely 
softened  and  disintegrated  by  cooking,  but  are  chemically 
converted  into  the  soluble  and  easily  digested  form  of  gela-. 
tin.  I  made  some  instructive  observations  on  the  effects 
of  cookino^  on  the  contents  of  the  eo-o-.  The  chansre  in- 
duced  by  cooking  on  egg-albumin  is  A^ery  striking.  For 
the  purpose  of  testing  this  point  I  employed  a  solution  of 
egg-albumin,  made  by  mixing  white-of-egg  with  nine  times 
its  volume  of  water.  This  solution  when  boiled  in  the 
water-bath  does  not  coagulate  nor  sensibly  change  its  ap- 
pearance, but  its  behaviour  with  the  digestive  ferments  is 
completely  altered.  In  the  raw  state  this  solution  is  at- 
tacked very  slowly  by  pepsin  and  acid,  and  pancreatic  ex- 
tract has  no  effect  on  it;  but  after  being  cooked  in  the 
water-bath,  the  albumin  is  rapidly  and  entirely  digested 
by  artificial  gastric  juice  and   a  moiety  of  it  is  rapidly  di- 


48  SUITABLE  FORMS   OF  FOOD.        [chap.  iv. 

gested  by  pancreatic  extract."  The  employment  of  raw 
meat  pounded  is  therefore  not  an  advantage  though  advo- 
cated by  some  medical  men.  Personally  I  have  never  seen 
a  case  in  which  raw  meat  seemed  to  be  indicated.  The 
connective-tissue  which  binds  the  fibrillse  of  muscle  to- 
gether, is  so  acted  upon  by  heat,  in  cooking,  that  the  fibres 
fall  readily  to  pieces  in  the  stomach;  and  so  are  easily 
acted  upon  by  the  solvent  gastric  juice.  Mastication  or 
chewing  breaks  down  the  masses  of  meat,  and  their  dis- 
integration is  completed  by  the  gastric  movements. 

Mastication,  as  a  disintegrating  matter,  is  separable 
from  the  admixture  of  starch  with  saliva  in  the  act  of 
chewing.  So  is  the  disintegrating  action  of  the  stomach 
separable  from  the  solvent  action  of  the  gastric  saliva. 
Mastication  exerts  no  influence  upon  albuminous  matters, 
of  a  solvent  character;  nor  does  the  action  of  the  stomach 
affect  fats,  except  by  the  solution  of  the  albuminous  enve- 
lopes which  surround  fat  as  found  in  the  bodies  of  animals. 
There  is  a  digestive  act  in  mastication,  viz.,  the  conversion 
of  starch  into  sugar  by  the  salivary  diastase:  and  a  pre- 
paration of  albuminoids,  for  the  action  of  the  gastric  juice. 
In  the  stomach  there  is  the  digestion  of  proteids,  and  the 
preparation  of  fats  for  the  action  of  the  bile  and  the  pan- 
creatic secretion,  by  the  digestion  and  solution  of  tlie 
albuminous  envelope  of  animal  fat — the  connective-tissue 
in  which  the  fat  globules  are  stored  in  the  body.  There  is 
then  preparation  for  coming  acts,  as  well  as  actual  solvent 
action  in  mastication,  and  th^e  gastric  portion  of  digestion. 

Now,  meats  differ  in  their  digestibility  according  to  their 
closeness  of  fibre,  and  the  firmness  with  which  the  fibres 


CKAjp.  IV.]        SUITABLE  FORMS   OF  FOOD.  49 

are  bound  together.  Pork,  veal,  beef,  mutton,  lamb,  stand 
in  the  inverse  order  of  their  digestibility  as  regards  the 
readiness  with  which  tlieir  fibres  fall  asunder.  The  effects 
of  cooking  upon  the  fibre  itself  probably  being  much  the 
same,  viz.,  the  effect  of  heat  u^^on  albumen  in  rendering  it 
more  easily  acted  upon  by  pepsin  and  trypsin.  The  hare 
and  rabbit  are  fairly  digestible  as  to  disintegration.  Then 
come  the  flesh  of  fowls  of  all  kinds;  the  finer  fibre  of  game 
being  specially  digestible.  Then  comes  the  flesh  of  fish; 
for  reptiles  are  not  a  part  of  an  ordinary  diet.  But  fish 
varies — the  Tunny  fish  tribe  are  hard  of  digestion.  Salmon 
is  often  dis^ested  with  difficultv,  and  so  is  fried  sole.  It  is 
not  merely  the  question  of  the  firmness  or  looseness  of 
fibre  only,  there  is  the  method  of  cooking;  where  the  fibres 
are  soaked  in  fat,  a  weak  stomach  cannot  digest  them  com- 
fortably ;  there  is  dyspepsia  often  with  the  eructation  of  a 
fatty  acid.  Then,  all  kinds  of  white  fish  are  most  digesti- 
ble, especially  when  boiled.  The  disintegration  of  muscu- 
lar fibre  in  the  preparation  of  meats  for  potting  is  complete; 
with  them  the  solvent  ]3art  of  the  digestive  act  is  alone 
required.  On  thin  stale  bread  with  the  butter  in  limited 
quantities  and  well  rubbed  into  the  tiny  holes  and  inter- 
stices of  (stale)  bread,  and  then  a  little  potted  meat  spread 
over,  a  very  digestible  little  meal  is  obtained-  Such  sand- 
wiches with  a  cupful  of  beef  tea  are  specially  indicated 
where  the  patient  cannot  take  milk. 

Then  there  are  the  vegetable  albuminoids  especially  the 
pulse  tribe,  or  legumes,  which  are  capitally  disintegrated  by 
cooking,  and  best  by  boiling  or  baking.  Thus  beans,  hari- 
cots and  broad,  peas,  lentils,  dahl,  &c.,  are  all  well  broken 


50  SUITABLE  FORMS   OF  FOOD.        [chap.  iv. 


u]3  by  heat.  The  disintegrated  flour  can  easily  be  passed 
through  a  sieve,  and  then  the  disintegration  factor  of  the 
digestive  act  is  disposed  of.  There  can  be  no  question 
about  the  fact  that  with  some  persons  vegetable  albu- 
minoids are  much  more  easily  digested  than  animal  albu- 
minoids; and  I  quite  agree  with  Sir  Henry  Thompson  in 
his  remarks  upon  this  subject.  Besides  too,  fat  spreads 
easily  over  the  disintegrated  particles  of  cooked  vegetable 
albuminoids,  as  is  well  seen  in  the  baked  beans  and  fat 
pork  of  New  England.  Indeed  by  such  means  fat  can  often 
be  taken  without  offence  to  a  stomach,  that  cannot  other- 
wise tolerate  it;  and  much  of  the  digestibility  of  fat  de- 
pends upon  the  fineness  of  the  particles  into  which  it  is 
sul^-divided.  Haricot  beans  well  boiled  passed  through  a 
sieve,  and  then  the  floury  part  mixed  with  milk  makes  an 
excellent  soup  ;  quite  equal  in  food  value  to  any  made  with 
meat  stock.  The  ordinary  lentil  soup  is  at  once  a  most 
economical  and  a  most  valuable  soup  for  ordinary  persons; 
though  scarcely  perhaps  quite  adapted  for  persons  with  in- 
digestion. But  "  the  proof  of  the  pudding  is  in  the  eating 
thereof," — if  it  does  not  disagree,  there  is  certainly  no  ob- 
jection to  its  use. 

Now  a  few  words  as  to  the  digestion  of  milk  caseine.  As 
milk  it  is  the  most  digestible  of  proteids,  i.e.,  with  those 
with  whom  it  agrees.  It  differs  in  its  digestion  from  other 
forms  of  albumen.  "  Milk  is  much  more  easily  digested 
by  pancreatic  extract  than  by  artificial  gastric  juice;  but  in 
the  case  of  egg-albumen  the  advantage  lies  decidedly  with 
the  gastric  juice."  Using  the  one  part  in  ten  of  water 
solution  of  egg-albumen  and  boiling  it  in  the  water  bath, 


CHAP.  IV.]        SUITABLE  FORMS   OF  FOOD.  51 

Dr.  Roberts  found  with  pepsin  and  hydrochloric  acid  the 
transformation  went  on  swiftly  and  without  interruption 
to  its  close.  Whilst  the  pancreatic  ferment  was  only  able 
to  convert  a  part  of  the  albumen  into  peptone.  There  is 
one  point  of  the  greatest  practical  moment  about  the  obser- 
vation, and  it  is  this — When  meat  or  e^g  digestion  is  to  be 
artificially  aided  it  is  well  to  use  pepsin  and  hydrochloric 
acid.  But  when  the  digestion  of  milk"  is  to  be  practically 
assisted  by  a  digestive  ferment,  it  is  desirable  to  use  trypsin ; 
the  pancreatic  secretion  in  an  alkaline  vehicle.  "  Tryptic 
digestion  of  milk  is  rapid  and  leaves  only  a  very  slight  resi- 
due— whereas  peptic  digestion  of  milk  is  slow,  and  leaves 
a  larg'e  residue." 

In  order  to  secure  exact  results  it  is  therefore  essential 
to  use  precise  means,  guided  by  the  light  physiological  ob- 
servation is  throwing  upon  this  hitherto  obscure  subject  of 
digestion. 

And  now  to  the  consideration  of  the  third  division  of  the 
subject,  the  digestion  of  fats. 

We  do  not  know  as  yet  any  change  exercised  upon  fat  by 
heat,  by  the  act  of  cooking,  except  that  of  rendering  it 
fluid.  Certainly  cooking  renders  fat  more  toothsome,  and 
in  the  case  of  fat  exposed  directly  to  great  heat,  as  in  the 
case  of  the  fat  of  a  beef  steak,  or  a  mutton  chop,  the  action 
of  the  heat  upon  the  albuminous  capsule  of  the  adipose 
tissue,  is  to  make  it  decidedly  tasty.  But  heat  does  liquefy 
fat,  and  separates  (we  believe)  olein,  from  stearin  andmar- 
garin.  The  liquid  portion  of  fried  bacon  is  digested  by 
many  who  cannot  digest  the  solid  portion  of  bacon  fat. 
This  is  a  well-known  fact.     The  fluid  is  the  olein.     Fats 


52  SUITABLE  FORMS   OF  FOOD.         [chap.  iv. 

var}'-  in  their  digestibility.  The  late  Dr.  John  Hughes 
Bennett  said:  "The  main  causes  of  tuberculosis  were  the 
dearness  of  butter  and  the  abundance  of  pastry  cooks;  the 
poor  not  getting  sufficient  fat,  and  the  upper  classes  dis- 
ordering their  digestion  by  puff  paste."  Now  butter  con- 
sists of  the  fat  globules  of  milk  removed  from  their 
envelopes  of  caseine  by  the  act  of  churning  ;  thus  getting 
rid  of  the  albuminous  enveloj)e  which  is  one  of  the  difficul- 
ties in  the  disrestion  of  animal  fat.  How  far  it  is  this  en- 
velope;  how  far  it  is  the  presence  of  firm  stearin  which 
constitutes  the  difficulty  in  the  digestion  of  animal  fats, 
in  each  case;  we  can  not  always  say.  Then  again  to  speak 
broadly,  the  lower  the  temperature  at  which  fat  ceases  to 
be  liquid  the  easier  its  digestion.  In  the  best  cod-liver 
oils,  the  stearin  and  margarin  are  taken  out  by  freezing; 
the  liquid  olein  being  poured  oif.  Beef  fat  and  mutton 
suet  are  less  digestible  than  lard,  bacon  dripping,  and 
butter;  the  latter  only  becoming  firm  at  a  much  lower 
temperature  than  is  sufficient  to  render  beef  and  mutton 
suet  hard.  Cod-liver  oil  is  the  most  easily  digestible  of  all 
forms  of  fat.  In  that  lies  its  great  utility.  It  can  be 
digested  when  other  fats  are  beyond  the  reach  of  the  diges- 
tive processes.  Some  have  thought  this  due  to  the  basyle 
with  which  the  fatty  acids  are  in  union,  being  propyline, 
instead  of  glycerine,  like  other  fats.  "  Others,  again,  have 
attributed  it  to  the  minute  quantities  of  iodine;  and  others 
to  the  biliary  matters  found  in  the  oil  ;  the  last  seems  far 
the  most  reasonable  supposition  "  (Lauder  Brunton).  In 
addition  to  this  there  seems  to  be  something  in  the  pre- 
sence of  a  little  free  fatty  acid,  as  found  in   certain  cod- 


CHAP.  IV.]        SUITABLE  F0E3fS   OF  FOOD.  53 

liver  oils.  "The  different  behavior  of  two  specimens  of 
the  same  oil,  one  perfectly  neutral,  and  the  other  containing 
a  little  free  fatty  acid,  is  exceedingly  striking.  I  have  here 
before  me  two  specimens  of  cod-liver  oil — one  of  them  is  a 
fine  and  pure  pale  oil,  such  as  is  usually  dispensed  by  the 
better  class  of  chemists  ;  the  other  is  the  brown  oil  sent  out 
under  the  name  of  De  Jorigh.  I  put  a  few  drops  of  each 
of  these  into  these  two  beakers,  and  pour  on  them  some  of 
this  solution,  which  contains  two  per  cent,  of  bicarbonate 
of  soda.  The  pale  oil  you  see  is  not  in  the  least  emulsi- 
fied ;  it  rises  to  the  top  of  the  water  in  large  clear  globules: 
the  brown  oil  on  the  contrary  yields  at  once  a  milky  emul- 
sion. The  pale  oil  is  a  neutral  oil,  and  yields  no  acid  to 
water  wdien  agitated  with  it — in  other  words  it  is  quite  free 
from  rancidity;  but  the  brown  oil  when  treated  in  the  same 
way  causes  the  water  with  which  it  is  shaken  to  redden 
litmus  paper."  (When  the  inhabitant  of  Arctic  regions 
prefers  his  fat  rancid,  probably  he  is  only  following  out 
what  experience  has  taught  him  is  good  in  his  liberal  con- 
sumption of  fat).  "  The  bearing  of  these  observations  on 
the  digestion  of  fat  is  plain.  When  the  contents  of  the 
stomach  pass  the  pylorus  they  encounter  the  bile  and  pan- 
creatic juice,  which  are  alkaline,  from  the  presence  in 
them  of  carbonate  of  soda.  So  that  the  fatty  ingredients 
of  the  chyme,  if  they  only  contain  a  small  admixture  of  free 
fatty  acids,  are  at  once  placed  under  favourable  circum- 
stances for  the  production  of  an  emulsion  without  the  help 
of  any  soluble  ferment,  the  mere  agitation  of  the  contents 
of  the  bowels  by  the  peristaltic  action  being  sufficient  for 
the  purpose  "  (Roberts).     Possibly  some  fats  containing  a 


54  SUITABLE  FORMS  OF  FOOD.        [chap.  iv. 

large  proportion  of  oleine  emulsioiiise  more  readily  than 
others.  But  the  whole  subject  is  in  its  infancy  so  far  as 
our  acquaintance  with  it  is  concerned.  Certainly  in  some 
cases  of  imperfect  digestion  of  fats  it  seems  that  a  pill  con- 
taining some  dried  oxgall  and  castile  soap,  taken  an  hour 
or  so  after  food,  is  indicated  as  likely  to  be  of  service. 

After  this  review  of  the  digestion  of  the  different  ingre- 
dients of  our  food,  we  can  see  the  digestion  of, 

Starch  by  saliva  and  pancreatic  diastase  ; 

Proteids  by  pepsin  and  trypsin  ; 

Fat  by  pancreatic  secretion  ; 
will  lead  us  to  the  proper  and  exact  use  of  artificial  diges- 
tive agents  :  about  which  at  present  the  wildest  confusion 
obtains  both  by  the  manufacturing  chemists  and  the  pro- 
fession generally.  The  chemists  may  take  umbrage  at  this 
statement,  but  they  will  find  a  difficulty  in  disposing  of  it. 
When  malt  preparations  are  directed  to  be  taken  after  food 
when  the  stomach  is  acid,  that  is  at  the  time  when  the  sali- 
vary diastase,  or  its  vegetable  substitute  is  at  once  rendered 
inert ;  when  malt  extract  is  added  to  cod-liver  oil  directed 
to  be  taken  "  during  or  immediately  after  a  meal,"  an  ad- 
mixture which  is  certainly  palatable  ;  but  the  vegetable 
diastase  is  little  likely  to  be  operative  in  the  acid  stomach, 
while  the  oil  is  taken  too  soon  to  be  acted  upon  :  a  com- 
bination which  is  certainly  not  physiological  ;  and  when 
an  emulsion  of  cod-liver  oil  and  pepsin  is  commended  by 
the  IBritish  Medical  Journal  in  a  recent  review,  dead  in  the 
teeth  of  all  that  physiology  teaches  us  (March  19th,  1881).* 

*  "Peptodyn,  a  combination  of  the  whole  of  the  digestive  secretions— 
pepsine,  pancreatine,  diastase  or  ptyalin,  etc. ,  forming  a  valuable  remedy 


CHAP.  TV.]        SUITABLE  FORMS  OF  FOOD.  55 

It  may  now  be  well  to  consider  the  use  of  Artificial 
Digestive  Agents  in  practice. 

First  it  may  be  desirable  to  consider  their  use  as  addi- 
tions to  the  natural  digestive  ferments  ;  and  then  to  pro- 
ceed to  the  use  of  artificially  digested  food. 

Starch  is  digested  by  the  salivary  diastase  while  the  food 
is  being  chewed,  and  in  the  stomach  before,  and  until  its 
contents  are  acid  ;  and  afterwards  by  the  diastase  of  the 
pancreatic  secretion.  The  latter  can  best  be  discussed 
when  artificial  pancreatic  secretion  is  spoken  of  ;  the  sali- 
vary diastatic  action  alone  will  be  reviewed  now. 

Starch  is  converted  into  sugar,  is  transferred  from  an  in- 
soluble to  a  soluble  matter  by  the  action  of  diastase  of  the 
saliva.  It  is  equally  well  acted  upon  by  the  diastase  pre- 
pared from  cereals,  i.e.^  the  digestive  diastase  of  the  embryo- 
plant.  Such  preparations  under  different  names  as  "malt 
extract,"  "  maltine,"  &c.,  are  now  placed  upon  the  market 
by  enterprising  manufacturing  chemists.  They  are  mainly 
given  to  children  ;  though  there  exists  no  reason  why  they 
should  not  be  more  largely  given  to  adults.  In  their  adop- 
tion it  must  be  borne  in  mind  they  act  upon  starch  solely 
and  exclusively,  and  have  no  effect  upon  other  articles  of 
our  food.     Sugar  does   not  require  them  ;    it   is   soluble 


in  the  treatment  of  dyspepsia,  and  diseases  arising  from  imperfect  nutri- 
tion— dose,  3  to  5  grains."  This  compound,  or  rather  "jumble,"  to  be 
taken  apparently  any  time  the  patient  prefers,  is  a  marked  illustration  of 
what  is  written  above  as  to  disregard  of  time  and  place  of  the  portions  of 
the  digestive  act.  (This  is  advertised  in  the  "  British  Medical  Journal," 
April  22nd,  1 881.) 


56  SUITABLE  FORMS  OF  FOOD.        [chap.  iv. 

■without  a  ferment.  But  for  starch,  liquefaction  precedes 
saccharification.  Consequently  "malt  diastase  "  should  be 
given  so  that  it  may  be  operative  before  the  contents  of  the 
stomach  become  acid.  It  should  tlien  be  added  to  milk- 
gruel,  and  milk  puddings,  before  they  are  taken  ;  or  at 
latest  immediately  after  they  are  sw^allowed,  and  before  the 
other  articles  of  a  meal  are  eaten.  Thus  with  children, 
their  milk  porridge,  made  with  oatmeal,  hominy,  or  crushed 
cereals,  should  be  taken  first  for  breakfast  with  the  malt 
with  them,  or  immediately  afterwards  ;  after  an  interval  a 
little  fat  bacon  or  cold  meat,  (ham  is  to  be  preferred),  may 
be  added,  with  bread  and  a  little  cocoa,  or  coffee  with  cream 
in  it.  Such  would  be  a  scientific  and  physiological  use  of 
vegetable  diastase  ;  which  is  a  treacly-looking  thing  as 
usually  seen,  of  sweet  taste,  and  therefore  well  adapted  to 
admixture  with  milk  porridge  immediately  before  being 
supped  ;  or  by  itself  immediately  afterwards.  While  chil- 
dren are  suckling  there  is  little  natural  diastase  found,  and 
it  is  not  till  the  sixth  or  seventh  month  that  it  is  found  in 
the  saliva  in  sufiicient  quantity  to  be  operative.  "  Until 
this  period  it  is  therefore  not  advisable  to  administer  fari- 
naceous food  to  infants."  It  would  seem  the  irritation 
set  up  by  the  teeth  excites  more  efficient  secretion  in  the 
salivary  glands. 

If  malt  diastase  cannot  be  given  as  recommended  above, 
it  will  be  well  to  continue  the  digestion  of  starch  by  resort 
to  artificial  pancreatic  secretion.  At  least,  that  is  the  con- 
clusion warranted  by  the  present  state  of  our  knowledge. 

Proteids,  or  albuminoids,  are  the  matters  specially  di- 
gested in  the  stomach.     "Proteids  are  attacked  by  the 


CHAP.  IV.]        SUITABLE  FORMS   OF  FOOT).  57 

digestive  ferments  at  two  points  in  the  alimentary  canal; 
by  pepsin  in  the  stomach,  and  by  trypsin  in  the  small  in- 
testine. Between  these  two  acts  of  digestion  there  is  a 
complete  break  in  the  duodenum,  owing  to  the  abrupt 
change  of  reaction,  from  acid  to  alkaline,  which  occurs  at 
that  point.  Gastric  digestion  is,  in  all  creatures,  an  essen- 
tially acid  digestion."  At  the  present  the  acid  gastric 
digestion  of  proteids  by  pepsin  is  being  considered  exclu- 
siv^ely. 

The  observations  of  Dr.  Beaumont  upon  Alexis  St. 
Martin,  who  had  the  front  wall  of  the  stomach  and  aJbdo- 
men  blown  away  by  a  gunshot  wound,  were  made  at  a 
time  when  our  pliysiological  knowledge  was  too  imperfect 
to  be  much  guide  to  him.  More  recently  C.  Richet  had  an 
opportunity  of  examining  the  act  of  gastric  digestion  in  a 
young  man  whose  stomach  was  artificially  opened  rf or  a 
stricture  of  the  o^ullet.  Thus  our  knowledo^e  is  not  con- 
fined  exclusively  to  the  observations  made  upon  animals. 
"  Richet  found  that  the  acidity  of  the  contents  of  the  sto- 
mach during  digestion,  although  it  varied  through  con- 
siderable limits,  had  a  marked  tendency  to  maintain  the 
normal  averasre.  If  acid  or  alkali  were  added  to  the  di- 
gesting  mass  the  mean  was  presently  restored  automati- 
cally— the  stomach  in  the  former  case  ceasing  to  secrete 
acid,  and  in  the  latter  case  secreting  an  increased  quantity 
of  acid."  Gastric  juice  contains  a  digestive  ferment  only 
active  in  an  acid  medium.  "The  reaction  is  distinctly 
acid,  and  the  acidity  is  normally  due  to  free  hydrochloric 
acid.  This  is  proved  by  the  fact  that  the  amount  of  hydro- 
chloric acid  is  more  than  can  be  neutralised  by  the  bases 
3* 


58  SUITABLE  FORMS   OF  FOOD.        [ohap.  iv. 

present.  Lactic  acid  and  butyric  and  other  acids  when 
present  are  secondary  jjroducts,  arising  either  by  their  re- 
spective fermentations  from  articles  of  food,  or  from  de- 
composition of  their  alkaline  or  other  salts  "  (M.  Foster). 

To  aid  this  portion  of  the  digestive  act  when  defective 
we  give  pepsin,  with  or  without  an  acid — usually  with 
hydrochloric  acid. 

Pepsin  is  precipitated  by  alcohol  in  great  quantity.  It  is 
sold  as  a  wine,  but  it  is  better  prepared  with  glycerine.  It 
is  sold  by  chemists  in  various  preparations.  It  is  com- 
monly sold  or  prescribed  along  with  hydrochloric  acid. 
*'In  gastric  juice  there  is  a  strong  tie  between  the  acid  and 
the  ferment,  so  strong  that  some  w^riters  speak  of  pepsin 
and  hydrochloric  acid  as  forming  a  compound  pepto-hydro- 
chloric  acid"  (M.  Foster).  "The  essential  property  of 
gastric  juice  is  the  power  of  dissolving  proteid  matters, 
and  of  converting  them  into  peptones  "  (Ibid.). 

When  then  we  resort  to  the  use  of  pepsin  as  an  artificial 
digestive  agent,  we  must  clearly  bear  in  mind  that  it  is 
the  digestion  of  albuminoids  solely,  that  we  can  assist  by 
its  means.  It  should  be  given  after  a  meal  has  been 
taken,  when  the  natural  gastric  solvent  is  being  poured 
out,  in  order  to  assist  that  solvent  in  its  digestive  action. 
It  is  then  useless  to  add  it  to  cod-liver  oil;  if  it  be  desir- 
able to  administer  both  these  agents,  let  the  pepsin  be 
given  early  after  a  meal,  when  it  will  be  serviceable;  and 
then  afterwards  the  oil,  when  its  time  arrives.  But  to 
combine  them  is  simply  to  set  the  lessons  of  physiology  at 
defiance;  to  ignore  the  place  and  time  of  the  different 
factors  in  the  digestive  act. 


CHAP.  IV.]        SUITABLE  FORMS  OF  FOOD.  59 

We  now  come  at  last  to  tlie  digestion  of  fat.  Hitherto, 
neither  in  the  diastatic  digestion  of  starch,  nor  in  the 
g-astro-pepsin  digestion  of  albuminoids,  has  fat  been  acted 
upon.  The  fat  of  adij^ose  tissue  is  liberated  from  its  albu- 
minoid envelope  in  the  stomach — that  is  all.*  But  when 
the  contents  of  the  stomach  pass  the  pyloric  ring  into  the 
duodenum,  and  are  mixed  with  the  bile,  then  fat  com- 
mences to  undergo  a  transformation.  It  is  not  digested  by 
anv  change,  or  metabolism  in  its  chemical  composition, 
any  hydration  by  the  addition  of  a  molecule  of  water,  as 
is  the  case  when  starcli  is  converted  into  sugar,  and  pro- 
teids  into  peptones;  it  is,  so  far  as  we  yet  know,  merely 
emulsionised.  This  emulsionising  of  fat,  by  the  reduction 
of  it  to  minute  globules,  renders  it  small  enough  to  be 
taken  up  by  the  intestinal  villi;  without  such  emulsionis- 
ing fat  could  not  enter  the  tiny  terminal  endings  of  the 
lacteals  in  the  villi  of  the  intestine.  For  such  emulsifica- 
tion,  an  alkaline  medium  is  essential.  The  bile  renders 
the  food  acid  in  the  stomach,  alkaline  in  the  intestines. 
In  an  alkaline  medium  the  pancreatic  secretion  is  active; 
and  in  an  alkaline  medium  onlv.     In  this  alkaline  medium 


^  Probably  even  the  digestion  of  the  albuminous  envelope  goes  on  in 
the  stomach  to  a  limited  extent  only.  As  the  envelope  is  digested,  the 
free  fat  remains,  and  so  prevents  the  acid  gastric  juice  from  acting  upon 
the  centre  of  the  piece  of  adipose  tissue.  Thus  the  periphery  only  is 
digested  in  the  stomach.  In  the  alkaline  medium,  so  soon  as  trypsin  dis- 
solves the  albuminous  corpuscles,  the  fat,  so  freed,  is  emulsionised,  and 
thus  the  trypsin  can  act  upon  the  internal  portion.  Thus  the  digestion 
of  fat,  even  as  adipose  tissue,  is  mainly  the  work  of  the  pancteas  aided  by 
the  bile. 


60  SUITABLE  FORMS  OF  FOOD.        [chap.  iv. 

the  pancreatic  diastase  resumes  the  digestion  of  starch; 
trypsin  converts  proteids  into  peptones;  and  fat  is  further 
emulsionised.  So  we  see  that  when  fat  assimilation  is  de- 
fective, the  use  of  an  artificial  pancreatic  secretion  aids 
the  further  digestion  of  starch  and  albuminoids,  as  well  as 
acting  upon  fat.  Consequently  when  we  resort  to  an  arti- 
ficial pancreatic  secretion,  we  must  take  care  to  see  that  it 
is  not  killed,  or  rendered  inoperative  for  ever  by  some 
gastric  acid  remaining  in  the  stomach.  It  is  this  "  acid 
gulf  "  in  the  stomach  which  we  have  to  guard  against,  else 
our  artificial  pancreatic  secretion  is  useless,  of  no  earthly 
avail.  It  is  necessary  then  to  protect  the  artificial  pan- 
creatic secretion  by  a  solution  of  soda;  and  soda  is  un- 
palatable, to  put  it  mildly.  Dr.  Roberts  therefore  advo- 
cates ten  or  fifteen  grains  of  bicarbonate  of  soda,  to  be 
taken  with  the  dose  of  Liquor  Pancreaticus  at  "  the  tail  of 
the  digestive  act."  This  passes  it  safely  through  the 
stomach:  just  as  a  guard  of  soldiers  sees  a  merchant  con- 
veyed over  an  unsettled  frontier  infested  by  robbers.  What- 
ever preparation  of  pancreatine  be  adopted  there  seems 
nothins:  for  it  but  the  alkaline  p-uard  to  see  it  throuo^h  the 
stomach.  An  oil  emulsionised  by  the  admixture  of  a 
small  quantity  of  bile  and  a  small  amount  of  pancreatic 
secretion  would,  in  all  probability,  aid  the  natural  j^an- 
creatic  digestion.  On  this  matter,  however,  we  can  only 
speculate  in  theory;  clinical  facts  alone  can  positively  de- 
termine the  matter.  The  proper  time  to  administer  the 
artificial  pancreatic  secretion,  is  when  the  contents  of  the 
stomach  are  finally  escaping  through  the  pyloric  ring,  at 
least  an  hour  and  a  half  after  an   ordinary  meal.     The 


cmvp.  IV.]        SUITABLE  FORMS   OF  FOOD.  61 

time  varies  in  different  individuals,  and  how  to  determine 
this  we  do  not  yet  know.  But  when  the  gastric  digestion 
is  over  no  more  juice  is  secreted,  and  what  lias  been  se- 
creted has  probably  spent  itself  upon  the  food-contents  of 
the  stomach.  The  alkali  neutralises  any  remaining  acid, 
and  so  protects  the  trypsin  from  the  deadly  effects  of  an 
acid  upon  it.  Soda  is  the  natural  alkali  in  bile  ;  and  / 
therefore  the  alkaline  guard  of  the  trypsin  should  be  a  / 
solution  of  soda. 

So  used  and  guarded  artificial  pancreatic  secretion  con- 
tains the  greatest  promise  in  dyspeptic  cases.  A  four- 
ounce  bottle  of  Liquor  Pancreaticus  contains  32  doses  of 
one  teaspoonful  (that  is  an  old-fashioned  small  teaspoon) 
or  rather  one  drachm  each.  To  give  32  doses  of  bicarbo- 
nate of  soda  (fifteen  grains),  involves  a  solution  of  one 
ounce  of  the  soda  in  sixteen  ounces  of  water  ;  dose,  one 
tablespoonful  with  each  teaspoonful  of  Liquor  Pancreati- 
cus. 

In  many  cases  the  administration  of  Liquor  Pancreaticus 
causes  the  most  satisfactory  improvement  in  the  patient's 
condition.  The  muscles  become  plump;  the  subcutaneous 
fat  once  more  fills  out  the  wrinkled  skin;  the  brain  is 
fed;  and  with  this  comes  back  the  lost  sense  of  energy,  of 
fitness  for  work. 

■  In  some  cases  the  disablement  of  the  digestive  organs 
is  such  that  it  becomes  imperatively  necessary  to  resort  to 
artificially  digested  food.  This  is  much  better  than  feed- 
inor  bv  the  bowel,  which  soon  becomes  so  painful  that  it  is 
impossible  to  continue  it.  Feeding  by  enemata  is  a  last 
resource,  only  to  be  adopted  in  critical  emergencies,  when 


62  SUITABLE  FORMS  OF  FOOD.        [chap.  iv. 

it  is  invaluable;  but  it  can  only  be  resorted  to  for  a  brief 
period.  In  acute  gastric  disturbance,  in  catarrh,  ulcer, 
and  cancer,  it  is  well  to  do  away  with  the  necessity  for 
movement  in  the  stomach  as  far  as  lies  in  our  power,  by 
giving  the  food  already  digested  to  a  great  extent. 

Milk  and  milk-gruel  can  readily  be  digested  by  the 
methods  advocated  by  Dr.  Roberts,  to  be  given  shortly. 

Partially  digested  foods  can  be  purchased;  but  person- 
ally, I  have  never  prescribed  them.  But  milk  and  milk- 
gruel  digested  by  the  Liquor  Pancreaticus,  have  done  me 
Yeoman  service  in  many  an  intractable  case. 

They  are  prepared  as  follows,  and  the  enema  appended 
is  worthy  of  careful  consideration;  when  an  enema  has  to 
be  resorted  to,  it  is  highly  important  that  it  have  as  high 
a  food  value  as  can  be  given  to  it. 

In  thus  giving  Dr.  Roberts'  directions  verbatim,  I  am 
hopeful  that  the  perusal  of  them  will  incline  many  readers 
to  order  the  liquor  pancreaticus  for  their  patients,  who, 
without  the  formulse,  might  not  see  the  practical  forms  in 
which  it  may  be  made  useful.  If,  in  doing  so,  I  can  in- 
cline some  to  try  this  preparation  who  might  otherwise 
have  remained  unacquainted  with  it,  it  will  be  gratifying; 
and  will  make  some  amends  for  the  loan  of  them  to  me  for 
my  book.  Here  the  reader  will  see  a  great  many  forms 
of  food  which  can  be  peptonised  with  advantage,  and  with- 
out destroying  their  toothsomeness. 

For  the  purposes  of  general  indigestion,  the  liq.  pan- 
creaticus is  mainly  indicated,  and  will  be  found  to  be  of 
much  advantage. 

In  those  cases  of  imperfect  assimilation  of  albuminoids, 


CHAP.  IV.]  PEPTOmSED  FOOD.  63 

where  tliere  is  a  plentiful  supply  of  fat  in  the  body,  but 
the  muscles  are  flabby  and  ill-nourished;  or  in  those  cases 
where  tliere  is  pain  and  discomfort  immediately  after  food, 
— the  cases  in  which  the  late  Dr.  Arthur  Leared  said  there 
was  dyspepsia  from  "insufficiency  of  gastric  juice;"  it 
may  be  Avell  to  give  the  liquor  j)epticus. 

1. — For  the  Preparation  of  Peptonised  Food. 

In  peptonising  or  partially-digesting  food  by  means  o£ 
**  Liquor  Pancreaticus  (Benger),"  it  is  important  to  remem- 
ber that  the  liquor  must  not  be  added  to  food  of  any  kind 
at  a  higher  temperature  than  140°  Fah.  This  temperature 
can  be  estimated  with  sufficient  accuracy,  should  no  suit- 
able thermometer  be  at  hand,  by  tasting.  If  too  hot  to 
sip  without  burning  the  mouth,  it  would  entirely  destroy 
the  activity  of  the  liquor  pancreaticus,  and  must  be  al- 
lowed to  cool  before  such  addition  is  made. 

Peptonised Milk. — A  pint  of  milk  is  diluted  with  a  quarter 
of  a  pint  of  water,  and  heated  to  a  temperature  of  about 
140°  F.  (60°  C),  (or  the  diluted  milk  may  be  divided  into 
two  equal  portions,  one  of  which  may  be  heated  to  the 
boiling  point  and  then  added  to  the  cold  portion,  the  mix- 
ture will  then  be  of  the  required  temperature.)  Two  or 
three  tea-spoonfuls  of  liquor  pancreaticus,  together  with 
ten  or  twenty  grains  of  bicarbonate  of  soda  (about  half  a 
small  tea-spoonful)  are  then  mixed  therewith.  The  mix- 
ture is  then  poured  into  a  covered  jug,  and  the  jug  is 
placed  in  a  warm  situation  under  a  cosey,  in  order  to  keep 
up  the  heat.    At  the  end  of  an  hour,  or  an  hour  and  a  half 


64  PEPTONISED  FOOD.  [chap.  iv. 

the  product  is  boiled  for  two  or  three  minutes.  It  can 
then  be  used  like  ordinary  milk.  The  object  of  diluting 
the  milk  is  to  prevent  the  curdling  which  would  otherwise 
occur  and  greatly  delay  the  peptonising  process.  The 
addition  of  bicarbonate  of  soda  prevents  coagulation  during 
the  final  boiling,  and  also  hastens  the  process.  The  pur- 
pose of  the  final  boiling  is  to  put  a  stop  to  the  ferment 
action  when  this  has  reached  the  desired  degree,  and  there- 
by to  prevent  certain  ulterior  changes  which  would  render 
the  product  less  palatable.  The  degree  to  which  the  pep- 
tonising change  has  advanced  is  best  judged  of  by  the 
development  of  the  bitter  flavour.  The  point  aimed  at  is 
to  carry  the  change  so  far  that  the  bitter  taste  is  distinctly 
perceived,  but  is  not  unpleasantly  pronounced.  The  ex- 
tent of  the  peptonising  action  can  be  regulated  either  by 
increasing  or  diminishing  the  dose  of  the  liquor  pancreaticus 
or  bv  increasing  or  diminishing  the  time  during  which  it  is 
allowed  to  operate.  By  skimming  the  milk  beforehand, 
and  restoring  the  cream  after  the  final  boiling,  the  pro- 
duct is  rendered  more  palatable  and  more  milk-like  in  ap- 
pearance. 

Feptonised  Gruel, — Gruel  may  be  prepared  from  any  of 
the  numerous  farinaceous  articles  which  are  in  common 
xise — wheaten  flour,  oatmeal,  arrowroot,  sago,  pearl  barley, 
pea  or  lentil  flour.  The  gruel  should  be  very  well  boiled, 
and  made  thick  and  strong.  It  is  then  poured  into  a 
covered  jug,  and  allowed  to  cool  to  a  temperature  of  about 
140°  F.  Liquor  pancreaticus  is  then  added  in  the  propor- 
tion of  a  table-spoonful  to  the  pint  of  gruel,  and  the  jug  is 
kept  warm  under  a  cosey,  as  before.     At   the   end  of  a 


CHAP.  ^^]  PEPTOmSED  FOOD.  G5 

couple  of  hours,  the  product  is  boiled,  and  finally  strained. 
The  action  of  the  pancreatic  extract  on  gruel  is  two-fold: 
the  starch  of  the  meal  is  converted  into  sugar,  and  the 
albuminoid  matters  are  peptonised.  The  conversion  of  the 
starch  causes  the  gruel,  however  thick  it  may  have  been  at 
starting,  to  become  quite  thin  and  w^atery.  Peptonised 
gruel  is  not  generally,  by  itself,  acceptable  food  for  in- 
valids, but  in  conjunction  with  peptonised  milk  (pepton- 
ised milk-gruel),  or  as  a  basis  for  peptonised  soups,  jellies, 
and  blanc-manges  it  is  likely  to  prove  valuable. 

Peptonised  Milh- Gruel. — This  is  the  preparation  of 
which  I  have  had  the  most  experience  in  the  treatment  of 
the  sick,  and  with  which  I  have  obtained  the  most  satis- 
factory results.  It  may  be  regarded  as  an  artificially  di- 
gested bread  and  milk,  and  as  forming  by  itself  a  complete 
and  highly  nutritious  food  for  weak  digestions.  It  is 
very  readily  made,  and  does  not  require  the  thermometer. 
First,  a  good  thick  gruel  is  prepared  from  any  of  the 
farinaceous  articles  above  mentioned.  The  gruel,  while 
still  boiling  hot,  is  added  to  an  equal  quantity  of  cold  milk. 
The  mixture  will  have  a  temperature  of  about  125°  F. 
(52°  C).  To  each  pint  of  this  mixture,  two  or  three  tea- 
spoonfuls  of  liquor  pancreaticus  and  twenty  grains  of  bi- 
carbonate of  soda  (half  a  small  tea-spoonful)  are  added. 
It  is  then  kept  warm  in  a  covered  jug  under  a  '  cosey,'  for 
a  couple  of  hours,  and  then  boiled  for  a  few  minutes,  and 
strained.  The  bitterness  of  the  digested  milk  is  almost 
completely  covered  in  the  peptonised  milk-gruel ;  and  in- 
valids take  this  compound,  if  not  with  relish,  without  the 
least  objection. 


66  PEPTONISEB  FOOD.  [chap.  iv. 

JPeptonised  Soups,  Jellies,  and  Ulanc- Manges. — I  have 
sought  to  give  variety  to  peptonised  dishes  by  preparing 
soups,  jellies,  and  blanc-manges  containing  peptonised 
aliments.  In  this  endeavor  I  have  been  assisted  by  a 
member  of  my  family,  who  has  succeeded  beyond  my  ex- 
pectations. She  has  been  able  to  place  on  my  table  soups, 
jellies,  and  blanc-manges,  containing  a  large  amount  of  di- 
gested starch  and  digested  proteids,  possessing  excellent 
flavor;  and  which  the  most  delicate  palate  could  not 
accuse  of  having  been  tampered  with.  Soups  were  pre- 
pared in  two  ways.  The  first  way  was  to  add  what  cooks 
call  *  stock '  to  an  equal  quantity  of  peptonised  gruel  or 
peptonised  milk-gruel.  A  second  and  better  way  was  to 
use  peptonised  gruel,  which  is  quite  thin  and  watery,  in- 
stead of  simple  water,  for  the  purpose  of  extracting  shins 
of  beef  and  other  materials  employed  for  the  preparation 
of  soup.  Jellies  were  prepared  simply  by  adding  the  due 
quantity  of  gelatine  or  isinglass  to  hot  peptonised  gruel, 
and  flavoring  the  mixture  according  to  taste.  Blanc- 
manges were  made  by  treating  peptonised  milk  in  the 
same  way,  and  then  adding  cream.  In  preparing  all  these 
dishes,  it  is  absolutely  necessary  to  complete  the  operation 
of  peptonising  the  gruel  or  the  milk,  even  to  the  final 
boiling,  before  adding  the  stiffening  ingredient.  For,  if 
liquor  pancreaticus  be  allowed  to  act  on  the  gelatin,  the 
gelatin  itself  undergoes  a  process  of  digestion,  and  its 
power  of  setting  on  cooling  is  utterly  abolished. 

Peptonised  JBeef-Tea. — Half  a  pound  of  finely  minced 
lean  beef  is  mixed  with  a  pint  of  water  and  tw^enty  grains 
(half  a  small  tea-spoonful)  of  bicarbonate  of  soda.     This  is 


CHAP.  IV.]  PEPTOmSED  FOOD.  67 


simmered  for  an  hour  and  a  half.  When  it  is  cooled  down 
to  about  140°  Fahr.  (60°  0.)  a  table-spoonful  of  the  liquor 
pancreaticus  is  added.  The  mixture  is  then  kej^t  warm 
under  a  cosey  for  two  hours,  and  occasionally  shaken.  At 
tlie  end  of  this  time,  the  liquid  portions  are  decanted  and 
boiled  for  five  minutes.  Beef-tea  prepared  in  this  way  is 
rich  in  peptone.  It  contains  about  4.5  per  cent,  of  organic 
residue,  of  which  more  than  three-fourths  consist  of  pep- 
tone ;  so  that  its  nutritive  value  in  reg-ard  to  nitroeenised 
materials  is  about  equivalent  to  that  of  milk.  When  sea- 
soned with  salt,  it  is  scarcely  distinguishable  in  taste  from 
ordinary  beef-tea. 

Another  loay. — One  pound  of  finely  minced  lean  beef  is 
mixed  with  a  pint  of  water,  and  simmered  for  an  hour  and 
a  half.  The  resulting  beef-tea  is  then  decanted  off  into  a 
covered  jug.  The  undissolved  beef-residue  is  beaten  with  a 
spoon  into  a  pulp  or  paste,  and  added  to  the  beef-tea  in  the 
covered  jug.  When  the  mixture  has  cooled  down  to  140° 
Fahr.  (or  when  it  is  cool  enough  to  be  tolerated  in  the 
mouth),  a  table-spoonful  of  the  liquor  pancreaticus  is 
added,  and  the  whole  well  stirred  together.  The  covered 
jug  is  then  kept  warm  under  a  cosey  for  two  hours  ;  at  the 
end  of  this  time  the  contents  of  the  jug  are  boiled  briskly 
for  two  or  three  minutes  and  finally  strained  ;  it  is  then 
ready  for  use. 

The  extreme  solubility  of  digested  products,  whether  of 
starch  or  of  proteids,  detracts  from  their  acceptability  to 
the  healthy.  To  them  they  appear  thin  and  watery;  they 
miss  this  sense  of  substance  and  soliditv  which  is  charac- 
teristic  of  their  ordinary  food.  But  to  the  weak  invalid 
without  appetite,  this  sense  of  substance  or  thickening  is 


68  PEPTOmSEB  FOOD.  [chap.  iv. 

generally  an  objection,  and  they  take  with  more  ease  an 
aliment  which  they  can  drink  like  water.  The  jellies  and 
blanc-manges,  on  the  other  hand,  give  to  invalids  of  more 
power  that  sense  of  resistance  and  solidity  which  is  desired 
by  those  of  stronger  appetite.  The  greater  variety  which 
can  now  be  o-iven  to  this  form  of  food  will  obviate  the 
monotony  sometimes  complained  of  under  the  continuous 
use  of  peptonised  milk-gruel. 

The  Use  of  Liquor  Paiicreaticus  as  an  Addition  to  Food 
shortly  before  it  is  Eaten. — Certain  dishes  commonly  used 
by  invalids — farinaceous  gruels,  milk,  bread  and  milk, 
milk  flavoured  with  tea,  or  coffee  or  cocoa,  and  soups 
streno-thened  with  farinaceous  matters  or  with  milk — are 
suitable  for  this  mode  of  treatment.  A  tea-spoonful  or 
two  of  the  liquor  pancreaticus  should  be  stirred  up  with 
the  warm  food  as  soon  as  it  comes  to  table.  And  such  is 
the  activity  of  the  preparation  that,  even  as  the  invalid  is 
engaged  in  eating — if  he  eat  leisurely,  as  an  invalid 
should — a  change  comes  over  the  contents  of  the  cup  or 
basin  ;  the  gruel  becomes  thinner  ;  the  milk  alters  a  shade 
in  colour,  or  perhaps  curdles  softly;  and  the  pieces  of 
bread  soften.  The  transformation  thus  begun  goes  on  for 
a  time  in  the  stomach  ;  and  one  may  believe  that,  before 
the  gastric  acid  puts  a  stop  to  the  process,  the  work  of 
digestion  is  already  far  advanced. 

This  mode  of  administering  liquor  pancreaticus  is  simple 
and  convenient.  No  addition  of  alkali  is  required,  and 
of  course  no  final  boiling.  The  only  precaution  to  be 
observed  is  that  the  temperature  of  the  food,  when  the 
extract  is  added,  should  not  exceed  150°  F.  (Go°  C). 
This  point  is  very  easily  ascertained  ;  for  no  liquid  can 


CHAP.  IV.]  PEPTONISEB  FOOD.  C9 

be  tolerated  in  the  mouth,  even  when  taken  in  sips,  which 
has  a  temperature  above  140°  (G0°  C).  If,  therefore,  the 
food  is  sufficiently  cool  to  be  borne  in  the  mouth,  the  liquor 
pancreaticus  may  be  added  to  it  without  any  risk  of  injur- 
ing the  activity  of  the  ferments. 

2. — For  Medicinal  ADiiiNiSTRAXiON. 

When  given  with  a  view  of  aiding  the  digestion  of 
starchy  food,  one  or  two  teaspoonfuls  should  be  admin- 
istered in  a  little  water  2cith  meals.  Taken  in  this  way 
it  acts  in  the  same  manner  as  Malt  Extract,  but  much 
more  powerfully. 

When  liquor  pancreaticus  is  given  with  a  view  of  aid- 
ing intestinal  digestion,  one  or  two  tea-spoonfuls,  with  a 
pinch  of  bicarbonate  of  soda,  dissolved  in  half  a  wdne-glass 
of  water,  should  be  taken  two  or  three  hours  after  a  meal. 

3. —Liquor  Pancreaticus  as  an  Addition  to  Nutritive 

Enemata. 

Liquor  pancreaticus  is  peculiarly  adapted  for  adminis- 
tration with  nutritive  enemata.  The  enema  may  be  pre- 
pared in  the  usual  way  with  milk-gruel  and  beef-tea  ;  and 
a  dessert-spoonful  of  liquor  pancreaticus  should  be  added  to 
it  ]ust  before  administration.  In  the  warm  temperature  of 
the  bowel,  the  ferments  find  a  favorable  medium  for  their 
action  on  the  nutritive  materials  with  which  they  are  mixed; 
and  there  is  no  acid  secretion  to  interfere  with  the  comple- 
tion of  the  digestive  process,  or  the  preparations  of  pepsin, 
or  of  the  vegetable  papuan,  which  is  a  most  potent  agent 
in  the  dig-estion  of  albuminoids— vegetable  though  it  be. 


CHAPTER  V. 

TISSUE  NUTRITION. 

"  Fkom  the  food  the  blood  is  fed  ;  from  the  blood  the 
tissues  are  fed."  In  the  first  place,  then,  we  must 
have  healthy  blood  for  the  formation  and  maintenance 
of  healthy  tissues.  The  blood  in  its  ceaseless  round 
carries  pabulum  to  the  tissues  of  the  body.  The  little 
artery,  with  its  vitalizing  fluid,  carries  a  sup^^ly  of  albu- 
minoid material  to  the  tissues  in  excess  of  their  wants. 
A  large  quantity  flows  on  through  the  capillaries  into  the 
corresponding  venule,  and  soon  rejoins  the  bulk  of  the 
circulating  fluid.  A  portion  of  the  serum  passes  through 
the  capillary  walls  and  feeds  the  tissue  ;  the  surplusage 
being  taken  up  by  the  lymphatics,  and  so  preserved 
for  future  use.  It  is  desirable  to  have  clear  views  about 
this  matter  of  tissue-nutrition.  The  whole  of  the  serum 
does  not  flow  through  the  capillaries  into  the  small  veins, 
a  part  passes  into  the  tissues.  In  order  to  maintain  a 
balance  betwixt  the  parts  and  their  supply  of  pabulum, 
there  is  the  lymphatic  vessel.  The  surplusage  is  taken 
up  by  this  lymphatic,  and  returned  to  the  blood  by  the 
thoracic  duct.  Thus  the  surplusage  is  removed  from  the 
tissue  and  saved  from  waste,  or  even  being  positively 
harmful.  If  the  surplusage  w^ere  not  removed,  there 
would  be  over-nutrition  of  the  part  with  hypertrophy. 
Thus,  when  John  Hunter  placed  a  cock's  spur  in  a  cleft 
made  in  the  bird's  comb,  the  spur  grew  to  a  most  abnor- 


CHAP,  v.]  TISSUE  miTRITIOK.  71 


mal  extent.  When  there  is  a  disturbance  in  this  natural 
balance  betwixt  supply  and  demand,  then  hypertrophy  is 
the  result.  The  son  of  a  friend  of  mine  wore  a  hio-h 
shoe  on  one  foot.  But  the  high  shoe  was  on  the  sound 
leg.  He  had  a  great  enlargement  of  the  other  leg  from 
obstruction  in  the  lymphatics,  and  it  grew  disproportion- 
ately from  the  excess  of  nutritive  fluid  in  the  tissues;  so 
much  so,  that  he  had  to  wear  a  high  shoe  on  the  foot  of 
the  normal  limb. 

Such  elongation  of  limbs  from  chronic  inflammation  in 
their  joints,  is  a  not-uncommon  phenomenon.  "SVe  know 
that  when  the  venous  system  is  engorged  from  valvular 
disease  of  the  heart,  we  get  a  development  of  pathological 
connective-tissue  in  the  different  viscera,  especially  the 
liver,  spleen,  and  kidneys;  though  the  lungs,  the  brain, 
and  the  uterus,  may  be  enlarged,  or  rendered  of  denser 
texture,  or  both.  Around  a  chronic  ulcer  there  is  a  vas- 
cular zone,  which  produces  epidermal  scales  in  excess, 
and  on  which  the  hairs  grow  to  a  gigantic  size.  Some 
diseases  tend  to  produce  local  disturbances  of  nutrition, 
notably  syphilis,  and  struma.  Syphilis  produces  nodes 
under  the  periosteum,  and  gummata  elsewhere, — active 
proliferation  of  connective-tissue  corpuscles.  Cancer  is 
the  production  of  histological  elements  out  of  place  or  out 
of  time.  Scirrhus  is  cartilag-e  where  no  cartilasfe  should 
be.  Colloid,  so  often  found  in  the  ovaries,  is  only  the 
sarcode  of  the  umbilical  cord.  Osteocephaloma  is  a  growth 
of  cells  from  the  bone  identical  with  the  cells  of  the  mar- 
row of  the  foetal  bones.  It  is  then  not  truly  lieteromorphic; 
it  is  normal  tissue,  out  of  place,  or  out  of  time.     Colloid 


72  TISSUE  NUTRITION.  [chap.  v. 

in.  the  ovaries,  marrow  cells  in  the  cancer  springing  from 
bone;  these  tell  of  an  association  which  is  certainly  not 
accidental. 

Struma  is  essentially  a  disease  of  hyperplasia  of  connec- 
tive-tissue; a  growth,  in  excess,  of  cells  of  inferior  quality. 
The  enlarged  glands,  the  thickened  epiphyses  of  the  long 
bones;  what  are  they  but  hyperplasia  of  elements  found 
there  normally  ?  The  neoplasm  is  an  inferior  or  degraded 
form  of  cell-life;  nothing  strictly  new.  In  tubercle,  there 
is  a  growth  of  lowly  cells  along  the  course  of  the  tiny 
arteries.  These  imperfect  cells  crowd  upon  each  other; 
and  if  this  crowding  goes  so  far  as  to  press  upon  the 
nutrient  arterioles,  then  there  is  danger  of  their  death,  of 
molecular  necrosis.  Thus  tubercle  softens,  breaks  down, 
and  is  expectorated.  If  the  crowding  of  these  imperfect 
cells  in  a  gland  passes  a  certain  point,  the  gland  structure 
breaks  down  into  a  scrofulous  abscess.  It  is  the  same 
method  of  procedure,  viz.,  the  development  of  cell  ele- 
ments about  the  nutrient  vessels,  Avhich  causes  the  ripe 
apple  to  drop  off;  which  fills  up  two  of  the  three  holes 
in  a  cocoa-nut,  and  then  gradually  fills  up  the  third,  till 
the  fibres  can  no  longer  bear  the  weight,  the  nut  drops 
off  from  its  attachment,  and  comes  to  the  ground.  '  So 
when  the  abnormal  cell  elements  accumulate  till  they 
press  on  the  nutrient  arteriole,  the  part  so  cut  off  from 
its  pabulum,  dies.  Thus  we  find  we  have  disturbances 
of  tissue — nutrition  in  the  direction  of  excess — of  excess 
of  quantity  with  deterioration  of  quality. 

Then  there  is  atrophy  from  mal-nutrition,  local  or 
general.       Phthisis,    consumption,    or    a    "wearing,"    the 


CHAT,  v.]  TISSUE  miTRITION.  73 


old  vulgar  term  for  wasting  disease,  is  general  mal-nu- 
trition  from  impairment  of  the  digestive  and  assimilative 
processes. 

Then  we  see  persons,  at  other  times,  with  flabby  ill-fed 
muscles,  yet  well  clad  with  fat.  Their  adipose  tissue  is' 
sufficiently  fed,  but  not  their  muscles.  Here  there  is  de- 
fective assimilation  of  albuminoids,  while  the  digestion  of 
starch  and  fat  is  normal  and  unaffected.  Indeed,  as  is 
well  seen  in  chlorotic  girls,  there  is  an  inverse  proportion 
established,  the  muscles  are  flabby,  while  there  is  a  posi- 
tive accumulation  of  fat.  They  are  breathless  ;  partly 
because  they  are  anremic,  partly  because  their  heart  and 
diaphragm  are  half-starved.  The  assimilation  of  albu- 
minoids is  impaired,  and  especially  is  the  formation  of 
that  complex  body  haemoglobin  interfered  with.  The  red 
corpuscles  are  deficient,  and  oxidation  is  impaired.  When 
improvement  is  inaugurated,  the  red  corpuscles  are  in- 
creased in  number  ;  the  muscles  fill  out,  while  the  fat  in 
the  body  is  diminished.  Such  are  the  various  steps  in  the 
process  of  the  restoration  of  health. 

Then  at  other  times  there  is  a  distinct  deficiency  in  the 
assimilation  of  fat.  One  of  the  difficulties  of  modern,  or 
rather  recent  times,  is  the  growing  inability  to  take  fat  ; 
children  now,  in  a  great  many  instances,  simply  loathe 
fat,  especially  a  lump  of  adipose  tissue.  They  can  take 
cod-liver  oil,  even  like  it,  they  can  take  the  fluid  fat  of 
fried  bacon,  they  can  take  butter;  but  animal  fat  en  masse 
they  turn  from  with  repulsion.  Granting  that  in  many 
instances,  the  objection  has  no  better  foundation  than  a 
silly  notion  that  it  is  "  vulgar "  to   eat  fat  ;   still,  there 


74  TISSUE  NUTRITION.  [chap.  v. 

remains  an  unpleasantly  large  proportion  in  whom  the 
repugnance  to  fat  is  genuine  and  unaffected.  When  this 
rejection  of  fat  has  proceeded  a  certain  length,  then  phthi- 
sis looms  up.  A  certain  amount  of  fat  is  apparently  es- 
sential to  the  formation  of  perfectly  healthy  tissue  ;  and 
when  the  system  is  imperfectly  supplied  with  fat,  then 
tissue  deterioration  is  apt  to  shew  itself.  This  holds 
good  of  animals  as  well  as  man.  Tubercle  is  common 
in  the  lungs  of  sheep  and  oxen  ;  and  it  is  quite  a  frequent 
occurrence  to  find  withering  tubercular  masses  in  the  ani- 
mals when  fatted — a  recovery  after  the  starvation  of  a 
previous  hard  winter.  When  starved,  or  partially  so, 
these  inferior  cell-elements  are  formed  ;  when  the  nutri- 
tion is  improved  then  normal  tissues  are  formed,  healthy 
and  sound, — and  the  lowly  histological  elements  wither. 
With  the  consumptive,  we  try  to  get  them  to  take  fat, 
the  easily  assimilable  cod-liver  oil  being  the  fat  mainly 
used  ;  but,  in  some  cases,  other  oils  or  cream  will  do  very 
well;  if  they  can  take  it  and  assimilate  it,  then  recovery 
takes  place.  Fat  is  so  furnished  for  histological  elements, 
and  then  the  tubercular  process  is  stayed;  and  the  patient's 
life  is  saved. 

It  is  not  asserted  that  this  is  all,  the  complete  whole,  of 
the  production  and  cure  of  tubercle;  but  it  is  an  important 
part  of  the  subject,  this  inability  to  assimilate  fat.  With- 
out a  sufficiency  of  fat  the  cell-elements  are  imperfect,  they 
are  produced  in  excess  with  deterioration  of  quality.  In 
the  present  state  of  our  knowledge,  we  are  unacquainted 
with  any  agents  which  act  directly  upon  tissue-nutrition. 
The  tissues  are  fed  from  the  blood;   and  "deteriorated 


CHAP.  T.]  TISSUE  NUTRITION.  75 

tissues  need  for  their  regeneration  the  baptism  of  healthy 
blood;  "  to  improve  the  blood  is  the  way  to  the  regenera- 
tion of  the  tissues.  We  can  only  feed  the  body  through 
the  blood;  the  blood  is  fed  from  the  food  we  eat.  If  we 
can  improve  the  blood,  we  can  feed  the  tissues. 

We  know  that  we  may  have  anaemia  with  fair,  indeed 
good  general  tissue-nutrition.  The  assimilative  and  con- 
structive processes  are  equal  to  the  commoner  tissues;  but 
they  cannot  build  up  hjemoglobin.  Haemoglobin  has  this 
formidable  looking  formula, 

^53.85>     -tl-7.325     -'^  16.17)     ^21.845     ^0.39)     -t*  G.43, 

with  some  3  to  4  per  cent,  of  water  of  crystallization 
(M.  Foster),  We  can  readily  understand  how  the  power 
to  construct  less  complex  bodies  may  be  retained,  yet  the 
capacity  to  build  up  hemoglobin  may  be  lost  for  a- time; 
and  require  medicinal  treatment  for  its  restoration.  We 
see  how  certain  blood-poisons,  lead,  mercury,  malaria, 
gout,  and  syphilis,  may  render  a  person  anoemic;  yet 
their  general  nutrition  may  be  little,  if  at  all  affected. 
We  know  that  when  there  is  such  a  toxic  element  pres- 
ent, iron  will  not  cure  the  anaemia,  however  potent  in 
simple  anaemia,  until  the  specific  in  each  case  be  added; 
and  then  improvement  sets  in.  With  the  two  mineral  poi- 
sons it  is  necessary  to  eliminate  them  from  the  system,  to 
relieve  it  from  their  presence,  ere  blood-formation  can 
proceed.  In  malaria  we  give  quinine,  in  gout  lithia  and 
potash,  in  syphilis  mercury  or  iodide  of  potassium,  with 
iron;  and  then  the  iron  is  operative;  without  the  specific, 
chalybeates  are  like  an  arrow  without,  a  head.  The  clinical 
relations  of   anaemia  teach  us   a  valuable  lesson  as  to   the 


76  TISSUE  NUTRITION.  [chap.  v. 

loss  of  power  in  the  system  to  construct  the  complex  sub- 
stance, haemoglobin. 

Another  lesson  in  the  same  direction  is  taught  us  by  the 
nervous  system;  the  loss  of  nervous  energy,  the  prostra- 
tion, the  unfitness  for  toil,  necessitating  a  holiday,  now 
so  commonly  experienced.  Here,  it  would  seem,  there  is 
impairment  of  the  ability  to  construct  lecithin.  Lecithin 
is  complex  fat  containing  phosphorus  and  nitrogen. 

"  Lecithin  C^,,  Hg^,  NPOg,  occurs  widely  spread  through 
the  body.  Blood,  gall,  and  serous  fluids  contain  it  in 
small  quantities,  while  it  is  a  conspicuous  component  of 
the  brain,  nerves,  yolk  of  egg^  semen,  pus,  white  blood, 
corpuscles,  and  the  electrical  organs  of  the  ray."  This 
is  what  Michael  Foster  says  about  lecithin.  The  well- 
known  association  betwixt  a  heavy  seminal  expenditure 
and  the  loss  of  nervous  energy,  upon  which  quacks  and 
charlatans  have  traded  so  largely,  is  thus  intelligible  and 
comprehensible.  Its  presence  in  the  electrical  organs  of 
the  ray  is  not  devoid  of  significance.  This  lecithin  is  a 
subject  upon  which  we  will  have  soon  to  know  more  than 
■we  do  at  the  present  time.  Just  as  the  complex  hasmo- 
globin  is  a  constitutent  factor  of  red  blood-corpuscles;  so 
we  will  find  this  complex  fat — lecithin — a  constituent  fac- 
tor of  nerve-cell  and  fibres.  We  do  not  know  enough  of  the 
subtle  changes  which  lie  at  the  foundation  of  the  loss  of 
nervous  energy,  so  well,  or  intimately,  as  the  associations 
of  aucTsmia;  but  there  is  much  pointing  in  this  direction, 
viz.,  that  it  is  linked  with  an  insufficiency  of  lecithin.  It 
is  either  used  up  too  freely  by  overwork,  or  worry,  which 
is  still  more  exhausting;   or  it  is  formed  imperfectly  from 


CHAP,  v.]  TISSUE  NUTRITION.  77 

some  impairment  in  the  assimilative  processes.  It  seems 
probable  that  this  complex  fat  is  the  food^ar  excellence  oi 
the  nervous  svstem.  That  without  it  nervous  enersrv  can- 
not  be  manifested.     Further  we  may  not  yet  affirm. 

But  it  is  perfectly  legitimate  to  throw  together  a  few 
clinical  facts  bearing  on  the  matter,  which  speak  with  a 
not  quite  inarticulate  sound.  When  the  nervous  system 
has  been  severely  overtaxed  for  a  considerable  time,  it  may 
give  out  evidences  of  exhaustion;  while  the  muscles  are 
well-nourished,  and  the  adipose  tissue  of  the  body  is  not 
diminished.  It  is  clear  that  here- there  is  a  localised  mal- 
nutrition, restricted  to  the  nervous  svstem.  The  serous 
fluids,  including  the  serum  of  the  blood,  contain  lecithin  in 
small  quantities;  therefore  exhaustion  of  this  substance  in 
the  nervous  system  would  require  time  for  its  repair;  and  if 
the  nervous  system  is  still  called  u23on,  it  must  furnish  evi- 
dences of  exhaustion  and  diminished  capacity,  until  the 
normal  proportion  of  lecithin  is  restored.  Rest  for  the 
nervous  system  permits  of  the  reaccumulation  of  this  com- 
plex phosphorized  fat.  Then  we  find  phosphorus  advo- 
cated for  nervous  exhaustion  and  depression.  "  Ohne 
phosphor  keine  gedanke,"  was  Moleschott's  dictum  now 
so  widely  known — ("  Without  phosphorus  there  is  no 
thought  ").  But  this  phosphorus  has  to  be  formed. into  a 
fat  before  it  can  be  of  service.  Not  onlv  thouo;ht,  but 
motor  messages  involve  the  oxidation  of  this  complex  fat. 
Lecithin,  cerebrin,  and  neurin,  are  complex  substances, 
found  in  the  nervous  system;  though  the  two  latter  are 
simpler,  not  containing  phosphorus.  But  the  decomposi- 
tion of  these  complex  bodies  is  essential  to  nervous  energy. 


78  TISSUE  miTRITIOm  [cH.iP.  v. 

Neuralgia  is  like  most  pain,  the  prayer  for  healthy  blood. 
*'  Pain  is  the  prayer  of  a  nerve  for  healthy  blood,"  wrote 
Romberg  ;  and  most  certainly  this  is  true  of  neuralgic 
pain.  Neuralgia  is  intimately  linked  with  the  presence 
of  poisons  in  the  blood — mineral,  malarial,  or  produced 
within  the  body.  Neuralgia  is  at  other  times  the  offspring 
of  simple  anaemia,  mere  bloodlessness.  Neuralgic  pain 
tells  of  unhealthy  blood;  blood  either  containing  a  positive 
poison,  or  itself  deficient  in  nutrient  material.  The  rest 
of  the  body  may  be  fairly  well  nourished;  but  neuralgia, 
and  a  sense  of  lethargy  or  unfitness  for  work,  may  tell  that 
the  nervous  system  is  underfed — that  the  organism  is  un- 
equal to  the  formation  of  those  complex  substances,  the 
food  of  the  nervous  system. 

So  far  as  we  know  it  is  in  the  preparation  of  these  corrx- 
plex  matters  for  the  blood  and  the  nervous  system — neither 
of  which  exists  in  plant  life — that  animal  synthesis  exhibits 
itself.  Bone  is  the  infiltration  of  lime  into  ordinary  car- 
tilage :  but  hemoglobin  and  lecithin  are  complex  bodies, 
built  up  in  the  animal  organism.  Starch,  sugar,  fat, 
are  built  up  from  carbonic  acid  and  water;  albumen  from 
these  and  free  ammonia  in  the  air.  All  are  synthetically 
built  up  by  vegetable  life,  and  appropriated  by  animals. 
Animals  evolve  energy  by  the  union  of  these  substances 
with  oxygen  ;  they  pull  to  pieces  and  oxidise  the  construc- 
tions of  plant  life,  and  in  doing  so  evolve  heat  and  force. 
But  the  oxygen-carrying  haemoglobin,  the  force-liberating 
lecithin,  are  essentially  the  creation  of  animals  themselves; 
who  build  them  up  from  less  complex  substances. 

The  complexity  of  these  nervine  matters  are  associated 


CHAP,  v.]  TISSUE  miTRITIOK.  79 

somehow  with  the  immense  "  liberating-power"  that  they 
possess.  The  respiratory  centre  occupies  a  little  space  in 
the  medulla,  but  its  rhythmic  discharges  set  off  a  large 
series  of  muscles;  and  when  its  explosions  are  stimulated 
by  the  presence  of  carbonic  acid  in  excess  in  the  blood,  all 
the  muscles  of  the  body  may  be  more  or  less  thrown  into 
action.  No  wonder  then  that  at  times  the  system  is  un- 
equal to  the  construction  of  these  elaborate  compounds; 
when  it  can  carry  on  successfully  the  digestion,  assimila- 
tion, and  transformation  of  ordinary  materials — built  up 
by  vegetables  originally,  and  appropriated  by  animals.  Xo 
wonder  either  that  when  the  power  to  build  up  these 
products  of  animal  synthesis  is  lost,  it  may  require  somes 
time  before  the  system  can  regain  it.  The  conversion  o\' 
spare  hydrocarbons  within  the  system  into  fat,  and  ever 
spare  proteids,  though  this  is  rather  fatty  histolysis,  and 
the  development  of  adipose  tissue  is  not  to  be  compared  tq 
the  construction  of  hsemoo-lobin  and  lecithin,  the  two  most 
complex  products  of  the  body;  the  two  which  must,  and 
only  can  be  built  up  by  animal  synthesis.  So  much  then 
for  the  loss  of  power  to  construct  complex  bodies. 

At  other  times,  there  exists  a  loss  of  power  to  assimilate 
albuminoids,  and  then  the  muscles  suffer  chiefly;  and  espe- 
ciallv  the  two  muscles  in  constant  action, — the  heart  and 
the  diaphragm.  This  is  a  practically  important  matter, 
as  a  heart  so  weakened  is  not  uncommonly  mistaken  for 
a  heart  undergoing  fatty  degeneration.  In  the  general 
evidence  of  loss  of  power  in  the  heart,  the  two  conditions 
are  almost  identical.  There  is  this  difference,  however, 
"  fatty  degeneration  "  is  a  condition  the  gravity  of  which 


80  TISSUE  JSrU-TRITIOJV.  [chap.  v. 

it  is  impossible  to  underrate;  while  "heart  starvation"  is 
a  condition  carrying  with  it  little  cause  for  apprehension, 
except  in  those  conditions  of  acute  failure  in  pyretic  states 
of  blood  poisoning,  where  the  heart's  action  becomes  ex- 
ceedingly rapid  and  fluttering;  a  condition  fraught  with 
extreme  danger.  But  "  heart  starvation "  as  ordinarily 
seen  is  a  condition  of  some  permanency,  and  not  a  truly 
"  acute  "  condition. 

When  the  digestion  of  albuminoids  is  defective,  then  the 
blood  cannot  furnish  to  the  muscular,  structures  the  pab- 
vdum  required  for  the  maintenance  of  their  integrity; 
consequently  they  are  ill-nourished  and  their  functional 
activity  is  impaired.  When  the  heart  is  so  enfeebled, 
and  the  diaphragm  also  half-starved,  then  there  are  dis- 
turbances in  the  circulation  which  closely  rese^/ible  the 
symptoms  of  tlie  fatty  heart.  The  heart-sounds  are  ill- 
defined,  and  less  audible  than  normal ;  while  the  heart's 
imjDulse  is  lost,  or  nearly  so.  The  pulse  is  feeble  and 
compressible.  There  is  a  tendency  to  fainting,  while  the 
mental  operations  are  confused,  the  brain  being  imper- 
fectly supplied  with  blood.  There  is  a  feeling  of  unsteadi- 
ness, or  lack  of  self-reliance,  which  is  very  distressing. 
The  patient  sighs,  and  there  are  seizures  when  the  respi- 
ration is  arrested.  Indeed,  the  symptoms  and  sensations 
are  those  given  by  Da  Costa,  in  his  admirable  work 
"Medical  Diagnosis,"  as  some  of  the  indications  of  the 
fatty  heart.  But  "  fatty  degeneration "  as  a  disease  of 
advanced  life,  is  distinctly  senile  in  its  aspect;  while 
"heart  starvation"  is  a  malady  of  middle  life.  One  pre- 
sents the  toict  ensemble  of  age, — of  widespread  senile  de- 


CHAP,  v.]  TISSUE  NUTRITIOir.  81 

generative  change;  the  other  is  rather  an  invalid,  as  a 
person  pulled  down  with  dysentery,  or  tropical  fever.  At 
a  distance,  the  tottering  gait,  the  unsteady  stejD,  the  bowed 
fissure  leanins:  on  a  stick,  mav  belona:  to  each  alike;  but  on 
nearer  approach,  the  resemblance  fades  out,  and  the  points 
of  dissimilarity  become  obvious.  Nevertheless,  it  is  by  no 
means  rare  to  see  cases  in  which  "  heart-starvation  "  has 
been  mistaken  for  the  "fatty  heart."  Indeed,  the  resem- 
blance is  so  close,  and  the  general  practitioner  has  so 
manv  thino-s  to  attend  to  on  the  one  hand;  while  on  the 
other,  our  acquaintance  with  the  heart  "  as  a  muscle  "  has 
not  kept  pace,  or  anything  like  it,  with  our  acquaintance 
with  the  valvular  diseases  of  the  heart,  of  which  the  "  mur- 
mur "  is  thQ  \nd\Qaiiion  i^ar  excellence ;  that  such  mistake 
does  not  always  involve  either  carelessness  or  culpable 
ignorance.  But  in  the  absence  of  the  significant  mur- 
mur, the  presence  of  distinct  debility  in  the  heart  is 
mystifying  to  the  ordinary  practitioner,  and  calls  up  the 
fear  of  "  fatty  degeneration;  "  and  not  unnaturally  so. 

The  knowledge  which  one  man  acquires  by  the  sweat  of 
his  brow,  after  years  of  patient  toil  and  painstaking  obser- 
vation, cannot  be  transferred  in  its  entirety  to  another  ; 
there  is  no  "  roval  road  "  to  knowleds-e. 

Individual  acquired  skill  cannot  be  passed  from  brain 
to  brain,  any  more  than  the  juggler  who  can  keep  six 
balls  in  the  air  at  once,  can  endow  an  onlooker  with  like 
capacity,  by  merely  showing  him  *'  how  it  is  done."  The 
muscles,  and  still  more  their  representatives  in  the  motor 
area  of  the  brain-hemispheres,  require  a  long  training 
before   this    manual   skill    can    be   acquired.      So    it  is  in 


82  TISSUE  NUTRITIOm  [chap.  v. 

other  matters.  It  is  not  difficult  to  say  how  the  diag- 
nosis betwixt  the  "fatty  heart"  and  "heart  starvation" 
is  to  be  made;  but  without  individual  toil  to  acquire  the 
requisite  capacity,  the  reader  cannot  attain  it.  There  is 
no  royal  road  to  the  discrimination  betwixt  two  allied 
conditions,  especially  when  the  resemblance  is  so  close 
as  it  is  betwixt  the  fatty  heart  and  its  double, — heart 
starvation. 

There  are  in  each  the  same  signs  on  physical  examina- 
tion of  the  heart;  in  each  the  same  cold  extremities,  indica- 
ting want  of  blood  in  the  arteries;  in  each  the  evidences  of 
cerebral  anaemia;  in  each  the  same  incapacity  for  exer- 
tion and  breathlessness  on  effort;  a  whole  group  of  symp- 
toms, indeed,  is  found  present  in  both.  But  in  the  fatty 
heart  there  are  found  evidences  of  senility  all  over  the 
bod\^  The  skin  is  degenerate,  unnaturally  smooth  and 
greasy,  or  furred  with  myriads  of  wrinkles;  the  eye  ex- 
hibits an  arcus  senilis  (arcus  is  a  "  bow,"  not  a  "  ring"), 
seen  under  the  upper  eyelid  long  before  it  is  present  in 
that  portion  of  the  eye  which  is  seen,  and  which  is  exposed 
to  light;  while  the  temporal  artery  is  seen  tortuous  and 
meandering  like  a  brook  in  a  flat  meadow.  He  was  a 
wise  man,  a  keen  observer,  and  an  accurate  thinker,  who 
said  "  a  man  is  no  younger  than  his  arteries  "  (S.  Wilks): 
and  it  is  the  condition  of  the  arteries  which  is  our  trustiest 
guide  in  making  the  diagnosis.  In  the  fatty  heart  the 
arteries  are  usually  atheromatous,  rigid,  and  tortuous. 
In  a  well-marked  case,  the  temporal  artery  may  be  seen 
to  elonofate,  as  well  as  to  widen  on  the  ventricular  svs- 
tole;  the  radial  artery  is   felt  to  undergo  the  same  tran- 


CHAP,  v.]  TISSUE  NUTRITIOX.  83 

sient  change.  The  arteries  feel  like  tendons,  or  even 
pipe-stems.  If,  at  the  same  time,  the  pulse  is  irregular 
or  intermittent,  then  the  fatty  heart  is  present  almost  to 
a  positive  certaint3\  But  where  evidences  of  age  are  want- 
ing, then  in  all  probability  the  condition  present  is  that  of 
heart  starvation  :  it  not  being-  denied  that  fattv  desrenera- 
tion  is  found  in  certain  rare  states  even  in  comparatively 
young  persons.  But  for  once  that  fatty  degeneration  is 
so  found,  fifty  times  fatty  degeneration  is  diagnosed  when 
heart  starvation  is  the  actual  state  of  matters.  The  disres- 
tion  of  albuminoids  is  defective  and  the  capacity  of  the 
heart  and  diaphragm  is  impaired  ;  furnishing  a  group  of 
symptoms  closely  resembling  those  manifested  when  the 
heart  is  the  subject  of  that  molecular  decay,  known  as 
fatty  degeneration,  or  necrosis.  Even  when  there  may 
be  ground  for  the  gravest  suspicion  as  to  the  integrity 
of  the  fibres  of  the  heart,  the  condition  may  still  be  one 
where  '^  starvation  "  is  also  present  ;  that  is,  there  is  act- 
ual degeneration  of  some  of  the  fibrillse,  while  there  is 
starvation  in  those  fibrillos  remaining  structurally  sound. 
Such  cases  are  met  with  from  time  to  time  (see  "Heart 
Starvation/'  H.  K.  Lewis  ;  reprinted  from  the  Edinburgh 
Medical  and  Surgical  Journal^  ^lay,  1881). 

Here  it  is  most  important  to  remember  that  a  small 
quantity  of  albuminoids,  properly  and  completely  digested, 
will  furnish  more  tissue-nutriment  than  a  large  meal,  none 
of  which  is  thorous^hlv  digested.  A  dietarv  of  fish,  white 
meat,  eggs,  milk-puddings,  with  fruit,  will  digest  and  feed 
up  a  starved  heart  and  diaphragm;  when  liberal  meals  rich 
in  meat  fail  to  do  so.     It  is  not  the  amount  swallowed,  it 


84  TISSUE  NUTRITION.  [chap.  v. 

is  the  amount  digested,  which  is  to  be  the  measure  of  the 
actual  nutritive  material  in  the  blood  ;  and  from  it  the 
nutrition  of  the  starved  tissues.  In  such  cases,  it  is  well 
to  aid  the  feeble  natural  digestive  powers  by  the  addition 
of  pepsin,  or  the  pancreatic  preparations.  It  is  somewhat 
difficult  to  induce  the  friends  of  the  patient  to  believe  that 
such  an  apparently  insufficient  dietary  is  the  one  cal- 
culated to  repair  debilitated  conditions  of  muscles  ;  but 
insistance  can  be  accompanied  by  explanation,  and  the 
results  convince  the  doubtful  and  convert  them  to  con- 
viction. 

Tlie  recognition  of  ill-fed  muscles  from  impairment  in 
the  power  of  assimilating  albuminoids,  as  a  condition  in- 
volving the  heart  and  diaphragm,  is  a  matter  which  must 
engage  the  attention  of  the  profession  in  a  little  time  ; 
indeed,  when  it  is  sated  with  nerve  pathology  and  poison- 
germs,  and  can  turn  its  attention  to  something  else. 

In  pernicious  anaemia  there  is  great  muscular  asthenia, 
and  the  heart  is  the  subject  of  actual  "  fatty  degeneration." 
There  is  a  growing  general  malnutrition  of  the  muscular 
system  especially,  though,  as  Addison  observed,  there  may 
,  be  an  increase  in  the  amount  of  subcutaneous  fat.  In- 
deed, in  anaemic  states,  fat  is  apt  to  be  deposited.  The 
farmer  often  bleeds  his  oxen  to  make  them  fatten,  when 
they  do  not  feed  satisfactorily. 

Tissue-nutrition  might  not  inappropriately  be  otherwise 
termed  "  protoplasmic  metabolism  or  digestion." 


CHAPTER  VI. 

SECONDARY  INDIGESTION. 
.  NE  UR  OSAL  .—REFLEX.  —  CA  RDIA  C. — TOXEMIC. 

We  now  come  to  the  consideration  of  those  forms  of  indi- 
gestion and  mal-assimilation  which  are  secondary  condi- 
tions, due  to  disturbances  elsewhere,  or  to  the  presence 
of  poisons  in  the  body.  These  will  be  found  to  be  a  large 
wide-spread  series. 

The  first  of  this  group  of  dyspepsiae  is  that  due  to  dis- 
turbance of  the  nervous  system,  as  overwork,  worry, 
anxiety,  suspense,  or  emotion;  w^here  the  encephalic  dis- 
turbance interferes  with  the  digestive  act.  "  How  thin 
you  are  getting  !  "  we  remark  to  an  acquaintance.  "  Yes, 
I  have  been  a  good  deal  worried  of  late;  I  have  a  lot  of 
work:  and  lately  I  have  had  a  good  deal  on  my  mind;"  is 
the  common  response.  Such  is  the  effect  of  mental  dis- 
turbance persisting  for  some  time.  Acute  indigestion  is 
the  result  of  sudden  perturbation.  "  That  the  secretion 
of  gastric  juice  is  affected  in  a  very  marked  manner  by 
conditions  of  the  nervous  system,  is  indicated  by  the  effect 
of  the  mental  emotions  in  putting  an  immediate  stop  to 
the  digestive  process,  when  it  is  going  on  in  full  vigour" 
(Carpenter).  We  all  are  only  too  familiar  with  the  con- 
sequences of  bad  news,  or  other  "  upset,"  when  at  m.eals. 
Unconscious  previously  of  the  possession  of  a  stomach,  or 
the  process  known  as  the  digestive  act,  we  suddenly  feel 
a  lump  in  the  epigastrium,  and  an  accompanying  convic- 


86  SECONDARY  INDIGESTION.  [chap.  vi. 

tion  that  the  meal  is  wasted.  This  is  the  effect  upon 
perfectly  healthy  persons;  more  marked  is  the  disturbance 
in  those  who  suffer  from  indigestion.  Vomiting  may  oc- 
cur, or  diarrhoea;  either  clearing  away  the  spoiled  victuals, 
but  by  a  process  the  reverse  of  pleasing.  If  neither  occur, 
then  the  undigested  material  is  the  source  of  disturbance 
for  some  time  afterwards.  The  reaction  of  this  upon  the 
nervous  system  is  productive  of  great  discomfort;  indeed, 
in  some,  acute  misery  is  induced  thereby. 

Dr.  Carpenter,  F.R.S.,  the  author  of  the  well-known 
works  on  Physiology,  has  paid  considerable  attention  to 
the  effects  of  mental  conditions  upon  the  organic  pro- 
cesses; and  it  may  be  well  to  make  several  quotations 
from  his  writings  on  the  subject.  By  so  doing,  the  reader 
will  be  put  in  possession  of  the  views  of  the  illustrious 
physiologist  ;  which  may  carry  with  them,  too,  more 
weight  than  my  unsupported  word.  After  giving  the 
effects  of  emotion  upon  other  secretions,  he  proceeds  to 
speak  of  those  connected  with  the  digestive  act. 

"  The  flow  of  saliva,  again,  is  stimulated  by  the  sight, 
the  smell,  the  taste,  or  even  by  the  thought  of  food;  espe- 
cially  of  such  as  is  of  a  savoury  character.  On  the  other 
hand,  violent  emotion  may  suspend  the  salivary  secretion; 
as  is  shewn  by  the  well-known  test,  often  resorted  to  in 
India,  for  the  discovery  of  a  thief  amongst  the  servants 
of  a  family — that  of  compelling  all  the  parties  to  hold 
a  certain  quantity  of  rice  in  the  mouth  during  a  few 
minutes,  the  offender  being  generally  distinguished  by 
the  comparative  dryness  of  his  mouthful  at  the  end  of 
the  experiment.    There  is  much  reason  to  believe  that  the 


CHAT.  VI.]         SECONDARY  INDIGESTION.  87 

secretion  of  tlie  gastric  fluid  is  affected,  in  the  same  man- 
ner as  that  of  the  saliva,  by  the  impressions  made  by  food 
upon  the  senses  ;  for  it  has  been  ascertained  by  Bidder 
and  Schmidt,  that  it  is  copiously  effused  into  the  stomach 
of  dogs  that  have  been  kept  fasting,  when  flesh  or  any 
other  attractive   food    is  placed   before   them.     That  the 
secretion,  on   the    other    hand,  is    entirely  suspended  by 
powerful  mental  emotion,  seems  almost  certain,  from  the 
well-known    influence    which    this  has  in    dissipating  the 
appetite  for  food,  and  in  suspending  the    digestive  pro- 
cess when    in  active  operation.      As  a   cheerful  state  of 
feeling,  on  the  other  hand,  seems  to  be  decidedly  favor- 
able to  the  performance  of  the  digestive  function;  it  prob- 
ably exerts  a  beneficial  influence,  as  to  both  quantity  and 
quality,  in  the  secretion  of  gastric  fluid,  of  the  influence 
of    mental    states,   or    other   secretions  concerned    in  the 
reduction  and  appropriation  of  the  food  (such  as  biliary, 
pancreatic,  and  intestinal  fluids),  neither  observation  nor 
experiment  has  as  yet  afforded  any  satisfactory  informa- 
tion.     It  is  a  prevalent,  and  perhaps  not  an.  ill-founded 
opinion,   that  melancholy  and   jealousy  have  a  tendency 
to  increase  the  quantity  and  to  vitiate  the  quality,  of  the 
hiliary  fluid.     Perhaps  the  disorder  of  the  organic  func- 
tions is  more  commonly  the  source  of  the  former  emotion 
than  its  consequence:  but  it  is  certain  that  the  indulgence 
of  these  feelings  produces  a  decidedly  morbific  effect  by 
disordering  the  digestive  processes,  and  thus  reacts  upon 
the  nervous  system  by  impairing  its   healthy   nutrition." 
This  last  is  a  very  significant  remark,  and  throws  much 
light  upon  many  cases  where  there  are  evidences  of  mal- 


88  SECONDARY  INDIGESTION.  [chap.  vt. 

nutrition  of  the  nervous  system,  taking  its  origin  in  emo- 
tional disturbance.  This  transient  disturbance  perturbs 
the  assimilative  processes;  and  these,  in  turn,  lead  to  per- 
sisting mal-nutrition  of  the  nervous  system. 

Again,  "there  is  abundant  evidence  that  a  sudden  and 
violent  excitement,  or  some  depressing  emotion,  especially 
terror,  may  produce  a  severe  and  even  a  fatal  disturbance 
of  the  organic  functions ;  with  general  symptoms  (as 
Guislain  has  remarked),  so  strongly  resembling  those  of 
sedative  poisoning,  as  to  make  it  highly  probable  that  the 
blood  is  directly  affected  by  the  emotional  state,  through 
nervous  agency;  and,  in  fact,  the  emotional  alteration  of 
various  secretions,  just  alluded  to,*  seems  much  more  prob- 
ably attributable  to  some  such  affection  of  the  blood,  than 
to  a  primary  disturbance  of  the  secreting  process  itself. 
Although  there  can  be  no  doubt  that  the  habitual  state 
of  the  emotional  sensibility,  has  an  important  influence 
upon  the  general  activity  and  perfection  of  the  nutritive 
processes  as  is  shewn  by  the  well-nourished  appearance 
usually  exhibited  by  those  who  are  free  from  mental 
anxiety,  as  well  as  from  bodily  ailment,  contrasted  witli 
the  "lean  and  hungry  look  "  of  those  who  are  a  prey  to 
continued  disquietude — yet  it  is  not  often  that  we  have 
the  opportunity  of  observing  the  production  of  change  in 
the  nutrition  of  any  specific  part,  by  strong  emotional  ex- 
citement. In  the  two  following  cases,  the  correspondence 
of  the  effects  to  their  alleged  causes  may  have  been  only 
casual ;  and  a  much  larger    collection  of  facts  would  be 

*  The  urine,  the  sexual  secretions,  the  sweat,  and  more  than  all,  the 
milk — ^the  secretion  of  the  mammary  gland. 


CHAP.  VI.]  SECONDARY  INDIGESTIOK  89 

needed  to  establish  the  rationale  here  advanced  as  probable. 
But  so  many  analogous  though  less  strongly-marked  phe- 
nomena are  presented  in  the  records  of  medical  experience, 
and  the  influence  of  the  emotions  upon  the  products  of 
secretion  is  so  confirmatory,  that  there  does  not  seem  any 
reasonable  ground  for  hesitation,  in  admitting  tliat  the 
same  explanation  may  apply  here  also.  The  first  of 
these  cases,  cited  by  Guislain,  from  Ridard,  is  that  of  a 
woman,  who,  after  seeing  her  daughter  violently  beaten, 
was  seized  with  o-reat  terror,  and  suddenly  became  affected 
with  gangrenous  erysipelas  of  the  right  breast.  But  a  still 
more  remarkable  example  of  local  disorder  of  nutrition, 
occasioned  by  powerful  emotion,  and  determined  as  to  its 
seat  by  the  intense  direction  of  the  attention  to  a  particu- 
lar part  of  the  body,  is  narrated  by  Mr.  Carter,  "  On  the 
Pathology  and  Treatment  of  Hysteria."  "  A  lady,  who 
was  watching  her  little  child  at  play,  saw  a  heavy  window- 
sash  fall  uj^on  its  hand,  cutting  off  three  of  its  fing^ers; 
and  she  was  so  much  overcome  by  fright  and  distress, 
as  to  be  unable  to  render  any  assistance.  A  suro-eon 
was  speedily  obtained,  who,  having  dressed  the  wounds, 
turned  himself  to  the  mother,  whom  he  found  seated, 
moaning  and  complaining  of  pain  in  the  hand.  On  ex- 
amination, three  fingers,  corresponding  to  those  injured 
in  the  child,  were  discovered  to  be  swollen  and  inflamed, 
although  they  had  ailed  nothing  prior  to  the  accident.  In 
four-and-twenty  hours,  incisions  were  made  into  them,  and 
pus  was  evacuated;  sloughs  were  afterwards  discharged, 
and  the  wounds  ultimately  healed."  The  influence  of  the 
state  of  exj)ecta)it  attention  in  modifying  the  processes  of 


90  SECONDARY  INDIGESTION.  [chap.  vi. 

nutrition  and  secretion,  is  not  less  remarkable  than  we 
have  already  seen  it  to  be  in  the  production  or  modifica- 
tion of  muscular  movements.  It  seems  certain  that  the 
simple  direction  of  the  consciousness  to  a  part,  indepen- 
dently of  emotional  excitement,  but  with  the  expectation 
that  some  change  will  take  place  in  its  organic  activity,  is 
often  sufficient  to  induce  such  an  alteration;  and  would 
probably  always  do  so,  if  the  concentration  of  the  atten- 
tion was  sufficient,"  This  last  matter  will  be  referred  to 
again  in  the  consideration  of  hysterical  dyspepsia,  and 
hypochondriasis.  It  has  certainly  much  to  do  with  the 
occurrence,  if  not  the  production,  of  the  '^ mother's  marks'* 
so  commonly  met  with. 

In  considering  the  question  of  how  emotion  affects  the 
digestive  process.  Dr.  Carpenter  says  experiments  have  not 
led  to  agreement  among  observers.  He  writes  "  Bernard, 
with  many  others,  considers  that  the  division  of  these 
nerves  (the  pneumogastrics),  instantaneously  checks  the 
secretion  of  the  gastric  fluid,  and  therefore,  puts  a  stop 
to  digestion;  and  he  points  to  the  pallor  and  flaccidity 
of  the  stomach  which  immediately  succeed  the  operation, 
the  slight  and  superficial  digestion  of  the  alimentary  mass 
■which  takes  place,  and  to  the  additional  circumstance,  that 
in  the  rabbit  there  is  a  sudden  change  in  the  reaction  of 
the  urine  from  alkaline  to  acid,  the  latter  being  the  normal 
condition  in  the  fasting  state,  and  therefore,  showing  that 
all  action  on  the  food  must  have  stopped.  He  further 
observes,  that  in  galvanising  the  pneumogastrics,  an  abun- 
dant flow  of  gastric  juice  takes  place.  Longet,  however, 
maintains,  that  division  of   the  pneumogastrics  operates 


chap:  n.]         SECONDARY  INDIGESTION.  91 

rather  in  paralysing-  the  muscular  movements  of  the 
stomach,  than  in  stopping  the  secretion  of  the  gastric 
juice;  for  he  states  that  if  a  small  quantity  of  milk  were 
given  to  the  animal,  24  or  even  48  hours  after  the  section, 
and  when,  therefore,  there  could  be  no  gastric  juice  re- 
maining in  the  stomach,  it  has  invariably  clotted  after 
death,  or  upon  making  the  animal  vomit;  and  small  quan- 
tities of  meat  or  other  food  were  dio^ested  readilv  enouofh, 
though  large  masses  were  only  superficially  digested, 
because  the  muscular  power  of  the  stomach  being  para- 
lysed, the  food  was  not  properly  intermingled  with  the 
gastric  juice." 

These  interesting  observations  point  to  several  matters 
of  clinical  moment.  They  tell  that  section  of  the  pneu- 
mogastric  nerves  arrests  the  secretion  of  gastric  juice 
with  *' pallor  and  flaccidity  of  the  stomach;"  that  is, 
the  arterioles  of  the  stomach  dilate  in  the  act  of  dig-es- 
tion,  when  the  mucous  lining  at  the  same  time  is  wet  with 
the  flow  of  the  gastric  juice.  Thus  we  see  that  both  (1) 
disintegration  by  the  muscular  movements;  and  (2)  the 
production  of  the  solvent  gastric  juice,  are  arrested;  no 
wonder  then  that  the  digestion  is  hindered !  Such  prob- 
ably is  the  effect  of  fear  and  depressing  emotions.  On 
the  other  hand,  galvanising  the  pneumogastrics  produces 
an  abundant  flow  of  gastric  juice.  This  is  analogous  to 
pleasant  emotions  aiding  digestion;  and  may  throw  some 
light  upon  the  time-honoured  practice  of  taking  wine  with 
food.  Paul  urged  upon  Timothy  to  "  drink  no  longer  water, 
but  have  a  little  wine  for  thy  stomach's  sake  and  thine  often 
infirmities;"  it  seems  probable  that  Timothy  had  indiges- 


92  SECONDARY  INDIGESTION:  [chap.  vi. 

tion  among  his  "  infirmities."  Pleasurable  emotions  of  a 
cheerful  enlivening  character,  act  like  a  stimulus  through 
the  pneumogastrics,  and  dilate  the  gastric  arterioles,  pro- 
moting the  secretion  of  gastric  juice;  while  increasing 
the  energy  of  the  muscular  movements  of  the  stomach. 
These  observations  are  in  perfect  accord  and  harmony 
with  our  practice  of  giving  agents,  which  so  act  upon 
the  stomach  when  the  digestive  act  is  defective.  Persist- 
ing emotions  act  in  the  same  way  but  less  potently, 
producing  the  same  results  through  longer  and  slower 
operations.  Thus  worry,  anxiety,  "  carking  care,"  and 
other  depressing  influences,  cause  a  persisting  loss  of 
flesh,  even  when  no  uncomfortable  sensations  are  com- 
plained of;  while  exhilarating  conditions  lead  to  more  per- 
fect and  complete  digestion  and  nutrition.  Shakespere 
wrote. 

"Let  me  have  men  about  me  that  are  fat  :  sleek-headed  men,  and 
Buch  as  sleep  o'nights.  Yond'  Cassius  has  a  lean  and  hungry  look  ;  he 
thinks  too  much  :  such  men  are  dangerous.  Would  he  were  fatter  !  But 
I  fear  him  not :  " — 

and  we  all  know  how  persons  emaciated  by  worry  and 
anxiety,  "pick  up  flesh,"  when  their  minds  are  once  more 
at  rest  after  much  perturbation. 

The  observation  that  "  small  quantities  of  meat  or  other 
food  were  digested  readily  enough,  though  large  masses 
were  only  superficially  digested "  is  one  pregnant  with 
instruction  as  to  the  dietetic  requirements  of  many  dyspep- 
tics. It  shows  that  when  the  digestion  is  impaired  small 
quantities  of  food  are  digested  "readily  enough;  "  while 
larger  amounts   were  only  digested   on    the    surface,  the 


CHAP.  VI.]         SECONDARY  INDIGESTIOy.  93 

interior  being  untouched.  Not  only  is  tlie  secretion  of 
gastric  juice  diminished  notably,  but  the  movements  are 
abolished  so  that  the  disintegration  is  not  accomplished, 
which  fits  the  food  for  admixture  with  the  bile  and  the 
pancreatic  secretion,  which  is  so  large  a  part  of  the  function 
of  the  stomach  ;  probably  more  important  than  even  the 
digestion  of  albuminoids  in  an  acid  medium,  because  this 
last  may  be  sui^jDlemented  by  the  pancreatic  digestion  of 
albuminoids  in  an  alkaline  medium.  It  shows  that  in  en- 
feebled assimilation  to  give  small  quantities  of  food  is  to 
secure  complete  digestion,  while  larger  meals  undergo  little 
digestion,  and  have  therefore  little  nutritive  value  ;  as  is 
insisted  upon  in  the  preceding  chapter  when  speaking  of 
the  dietary  in  "heart  starvation."  Such  then  is  a  part  of 
the  aid  which  physiological  research  can  give  to  practical 
medicine. 

Impaired  nutrition  is,  then,  often  the  direct  outcome  of 
mental  disturbance.  The  most  pronounced  inveterate 
case  of  anEemia,  I  ever  met  with  personally,  occurred  in  a 
girl  of  splendid  physique  and  magnificent  family  history. 
She  was  the  type  of  health  when  her  father  fell  down  by 
her  side  at  market,  and  died  there  and  then.  She  imme- 
diately became  ansemic  and  remained  so,  despite  most 
varied  treatment. 

Pernicious  anagmia  about  which  so  much  has  been  written 
lately,  is  probably  a  perversion  of  nutrition  due  to  nervous 
disorder,  rather  than  a  local  disease,  "  atrophy  of  the 
gastric  glands  ; "  if  atrophy  of  the  gastric  glands  is  ac- 
tually found  after  death,  it  is  probably  the  consequence, 
rather  than  the  cause  of  the  anaemia  ;  instead  of  being  a 


94  SECONDARY  INDIGESTION.  [chap.  vi. 

rational  explanation,  in  the  face  of  the  powers  of  the 
pancreatic  secretion,  it  seems  rather  like  "putting  the  cart 
before  the  horse."  It  is  a  case  of  distinct  loss  of  the  power 
to  assimilate  albuminoids,  a  matter  discussed  in  the  pre- 
ceding chapter.  It  appears  that  "  there  is  often  a  consider- 
able amount  of  subcutaneous  fat  ; "  yet  "  almost  without 
exception  the  heart  is  in  a  state  of  fatty  degeneration  ;  its 
walls  are  pale,  flaccid  and  friable  ;  the  interior  of  the  ven- 
tricles, and  especially  of  the  left  ventricle,  shows  irregular 
whitish  striiB  running  transversely  across  the  muscular 
bundles,  and  especially  the  j^apillary  muscles  "  (S.  Coup- 
land).  It  is  a  disease  only  observed  in  recent  times  ;  and 
is  one  of  the  increasing  number  of  perversions  of  nutrition 
with  which  we  are  becoming  familiar  now-a-days. 

The  mental  associations  of  diabetes  are  very  interesting 
in  relation  to  this  subject.  Talking  one  day  with  Mr. 
Van  Abbott,  whose  biscuits  for  diabetics  have  such  a  well- 
deserved  renown,  I  asked  him, — "Who  are  your  diabetics 
mostly  ?  "  The  reply  was  very  significant — "  Business  men 
comparatively  old  and  grey  for  their  years  ;  men  who  look 
as  if  they  had  a  deal  on  their  minds."  This  was  the  re- 
sponse. It  stands  in  a  suggestive  relationship  to  the  fact 
of  acute  diabetes  being  set  up  by  shock  or  other  mental 
perturbation  ;  or  of  its  artificial  production,  by  the  puncture 
of  the  floor  of  the  fourth  ventricle.  The  direct  nervous 
connection  betwixt  the  brain  and  the  liver  has  been  shown 
by  Cyon  and  Aladoff.  It  contrasts  with  the  mere  glyco- 
suria, so  common  in  stout  men,  where  the  digestion  of 
starch  is  perfect,  and  the  liver  only  dehydrates  enough 
into  glycogen  for  the  wants  of  the  system  ;  the  surjolusage 


CHAP.  VI.]         SECONDARY  INDIGESTION.  95 

running  off  by  the  kidneys.  Here,  if  it  were  not  for  this 
"  waste  pipe,"  the  individuals  would  become  inordinately 
fat.  Such  glycosuria  is  a  totally  different  matter  from  the 
diabetes,  which  leads  to  wasting;  where  either  (1)  the 
liver  has  lost  the  power  of  dehydrating  the  sugar,  brought 
to  it  by  the  portal  vein,  the  more  probable  hypothesis;  or 
(2)  the  ferments  in  the  liver  hydrate  the  glycogen,  or 
animal  starch  into  suga-r  again,  too  swiftly  for  the  wants 
of  the  body;  and  the  " fuel-food "  escapes  unburnt.  In 
either  case  it  becomes  necessary  to  feed  the  patient  on 
food  which  is  not  saccharine,  and  therefore  liable  to  these 
perversions  of  dehydration,  and  secondary  hydration.  If 
food  can  be  taken  in  sufficient  quantity  and  assimilated, 
which  underofoes  no  saccharine  transformation,  the  dia- 
betic  is  preserved:  if  not  he  perishes.  S.  Haughton,  F.R.S. 
tells  of  the  diabetic  patient  dying  of  inanition,  that  in  the 
delirium  which  precede.d  the  final  change,  he  cried  out 
"  Fat !  roasted  fat  from  the  angels  of  heaven!  " 

Such  perversion  of  the  assimilative  processes  which  is  so 
marked  in  its  various  forms  at  the  present  day,  will  be 
considered  in  relation  to  its  rapid  increase,  and  the  pros- 
pects of  the  next  generation  and  their  successors, — if  they 
have  an}^ — in  a  succeeding  chapter.  The  failure  of  the 
teeth  it  will  be  seen  is  but  one  part,  one  factor  in  a  wide- 
spread deterioration  of  the  digestive  processes.  The  ter- 
rific demand  upon  the  nervous  system  in  the  present 
"  struggle  for  existence,"  and  "  fight  for  a  competency  "  is 
telling  with  deadly  effect  upon  the  organic  processes  and 
their  nutritive  products.  Not  only  do  we  recognize  men- 
tal factors  in  the  production   of  the   disturbance   of  the 


96  SECONDARY  INDIGESTION.         [chap.  yi. 

digestion,  in  the  digestive  act  in  the  stomach — ordinarily 
spoken  of  as  if  it  were  the  whole  of  the  digestive  act;  but 
we  see  the  liver  may  be  disordered  by  mental  disquietude. 
Jaundice  has  been  known  to  be  produced  by  fright,  and 
more  chronic  functional  disturbance  of  the  liver  is  linked 
with  persisting  mental  perturbation.  Diabetes  is  set  up 
acutely  by  mental  emotion;  chronic  overwork  leads  to  a 
more  lasting  form  of  mental  taxation.  Recently  Clifford 
Allbutt,  F. R.S.J  urged  with  his  wonted  able  advocacy,  the 
mental  relationships  of  chronic  renal  disease.  In  his 
opinion  enduring  mental  anxiety  and  worry  over  business 
difficulties,  is  a  potent  factor  in  the  production  of  chronic 
Bright's  disease  with  albuminuria. 

Indeed  a  huge  mass  of  evidence  is  being  collected  to 
show  that  excessive  toil  in  that  portion  of  the  brain  which 
is  devoted  to  intellectual  processes,  leads  to  deterioration 
of  the  functions  of  the  viscera,  which  form  part  of  the 
organic  life.  The  viscera  which  provide  the  pabulum  for 
the  intellectual  and  motor  processes,  i.e.  the  brain  and 
muscular  system,  become  affected  in  time  by  the  demand 
upon  them,  and  give  way  under  the  strain. 

More  pronounced  is  this  effect  when  the  posterior  lobes, 
which  are  linked  with  our  subjective  states  and  our  emo- 
tions, are  involved.  Loss  of  appetite,  of  the  power  of 
all  digestion  is  the  common  outcome  of  acute  grief.  The 
production  of  new  matters  in  the  blood  is  shown  by  the 
hair  turning  grey  suddenly;  even  in  a  single  night,  as  was 
the  case,  it  is  said,  with  Marie  Antoinette  and  the  Prisoner 
of  Chillon.  It  is  quite  common  to  see  the  hair  acquire  a 
distinct  grey  hue  when  a  person  is  subject  to  acute  severe 


CHAP.  VI.]         SECONDARY  INDIGESTION.  97 

mental  trouble,  a  lawsuit,  the  death  of  a  loved  relative, 
intense  suspense  in  speculation  or  business,  indeed  any 
cause  of  profound  emotion;  and  to  see  it  lose  this  tempo- 
rarily acquired  hue,  when  the  cause  of  the  mental  pertur- 
bation has  either  passed  away,  or  the  blow  has  been 
softened  by  time.  The  secretion  of  milk  in  woman  is 
profoundly  affected  by  mental  emotion,  indeed  may  become 
a  deadly  poison.  Sir  Astley  Cooper  observed  two  cases 
of  arrest  of  the  secretion  from  emotion  and  wrote — "Those 
passions  which  are  generally  sources  of  pleasure,  and 
which,  when  moderately  indulged,  are  conducive  to  health, 
when  carried  to  excess,  alter,  and  even  entirely  check,  the 
secretion  of  milk."  According  to  Dr.  Carpenter,  many 
observers  have  noticed  fits  of  passion  in  a  suckling  mother 
followed  by  convulsions  and  death  in  the  infant  after  being 
put  to  the  breast.  Thus,  in  one  case  a  tumult  arose 
between  a  soldier  and  a  carpenter  in  whose  house  he 
was  billeted  ;  the  carpenter's  wife  rushed  in,  wrested  the 
sword  from  the  soldier,  and  broke  it  in  pieces.  "  While 
in  this  strong  excitement,  the  mother  took  up  her  child 
from  the  cradle,  where  it  lay  playing,  and  in  the  most 
perfect  health,  never  having  had  a  moment's  illness;  she 
gave  it  the  breast,  and  in  doing  so  sealed  its  fate.  In  a 
few  minutes  the  infant  left  off  sucking,  became  restless, 
panted,  and  sank  dead  upon  its  mother's  breast."  It  is 
clear  that  the  disorder  in  the  secretion  provoked  by  mental 
emotion  produces  some  very  active  poison,  acting  rapidly 
upon  the  nervous  system  with  deadly  effect.  Convulsions 
usually  are  provoked  ;  nor  is  this  perversion  of  secretion 
in  emotion  confined  to  human  beings,  Carpenter  writes, 


98  SECONDARY  mDIGESTION.         [chap.  vi. 

"Another  case  was  that  of  a  puppy,  which  was  seized  with 
epileptic  convulsions,  on  sucking  its  mother  after  a  fit  of 
rage." 

Such  are  the  acute  perversions  which  produce  toxic 
matters  in  the  milk  of  a  mother  when  she  is  emotionally 
excited. 

The  mental  disturbance  sets  up  modifica,tions  of  secre- 
tion which  result  in  the  formation  of  a  poison  acting 
mainly,  if  not  entirely,  upon  the  nervous  system. 

So  in  more  chronic  and  persisting  conditions.  A  men- 
tal upset  disturbs  the  nutritive  processes,  and  the  changes 
so  induced  react  upon  the  nervous  system:  consequently 
we  can  comprehend  how  persisting  depraved  nutrition  can 
be  traced  to  a  particular  period  of  mental  disturbance  by 
the  sufferer,  with  a  fair  show  of  reason  for  what  is  stated. 
The  most  intractable  case  of  dyspepsia  with  malaise, 
lethargy,  inability  for  exertion,  a  disordered  state  of  the 
bowels,  with  furred  tongue,  a  hot  bitter  taste  in  the  mouth 
on  waking;  all  the  evidences  indeed  of  disordered  diges- 
tion with  the  production  of  abnormal  "by-products  of 
digestion,"  which  ever  came  under  my  notice,  was  that 
of  a  returned  East  Indian.  This  gentleman  came  of  a 
healthy  stock,  was  a  well  nourished  person,  took  a  very 
high  place  in  the  examination  for  the  East  Indian  Civil 
Service;  continued  his  labours;  took  one  thing  after 
another,  far  outstripping  all  his  competitors:  with  what  re- 
sult ?  This!  His  digestive  apparatus  became  so  thoroughly 
disordered  that  he  was  compelled  to  retire  from  duty,  to 
come  home  to  England,  to  do  nothing.  A  confirmed 
dyspeptic,   his   bodily   comfort   destroyed,  his   prospects 


CH.\p.  Yi.]  SECONDARY  INDIGESTION.  99 

clouded  darkly,  crippled  in  the  race  for  life;  he  has  to  sit 
helplessly  looking  on,  while  his  old  competitors  diminish 
the  space  betwixt  him  and  them,  and  then  overtake  him  ; 
after  that,  see  them  going  onward  leaving  him  hopelessly 
behind.  If  he  were  not  a  man  of  high  moral  principle  he 
would  be  driven  to  suicide ! 

Another  more  ordinary  case  was  that  of  a  gentleman  in 
a  business  house  in  South  AYales.  He  had  charo;-e  of  a 
branch  of  the  business,  was  an  energetic  active  man,  in- 
dustrious, persevering,  and  painstaking.  Feeling  it  would 
be  an  advantage  to  be  acquainted  with  the  French  lan- 
guage, he  sat  up  at  nights  to  learn  it.  Under  this 
additional  strain  his  health  broke  down.  He  seemed 
rather  surprised  when  told  that  he  had  been,  from  a 
medical  point  of  view,  guilty  of  a  piece  of  consummate 
folly:  for,  from  a  business  point  of  view  his  conduct 
merited  the  highest  commendation.  He  omitted  from  his 
calculation  the  matter  of  his  health.  His  dior-estion  broke 
down,  he  began  to  sweat  at  nights,  and  his  left  lung 
w^as  not  above  suspicion.  Fortunately  his  employers, 
knowing  his  value,  took  alarm  and  sent  him  to  me  at  once, 
before  the  mischief  had  gone  any  length.  He  was  put 
upon  tonics,  and  advised  to  go  a  trip  into  the  Mediterranean 
in  one  of  their  vessels  ;  and  then  to  go  to  France  for  a  time, 
so  as  to  acquire  the  language  without  overworking.  The 
result  of  his  overwork  was  a  breakdown:  a  very  common 
matter.  He  just  lost  the  time  which  would  have  enabled 
him  to  have  acquired  French  in  a  less  violent  hurry.  He 
is  now  well  and  free  from  any  chest  ailment. 

Such  then  are  examples  of  a  class  of  case  sadly  too  nu- 


100  SECONDARY  INDIGESTION.  [chap.  vi. 

merous  at  the  present  time.     In  this  generation  men  will 
not  be  content  to  move  at  the  leisurely  pace  of  their  grand- 
fathers. Mr.  Deane,  in  "  The  Mill  on  the  Floss,"  spoke  to  his 
nephew  Tom  Tulliver  as  follows:—"  The  world  goes  on  at  a 
smarter  pace  now  than  it  did  when  I  was  a  young  fellow. 
^A'hy,  sir,  forty  years  ago,  when  I  was  much  a  strapping 
youngster  as  you,  a  man  expected  to  pull  between  the  shafts 
the  best  part  of  his  life,  before  he  got  the  whip  in  his  hand. 
The   looms  went   slowish,  and  fashions  didn't  alter  quite 
so  fast;  I'd  a  best  suit  that  lasted  me  six  years  !     Every- 
thing was  on  a  lower  scale,  sir,  in   point   of  expenditure, 
I  mean.     It's  the  stream,  you  see,  that  has  made  the  dif- 
ference; it  drives  on  every  wheel  double    pace,  and  the 
wheel  of  fortune  with  'em."     And  so  men  push,  and  strive, 
and  struo:a:le,   and  attain    their  end, — or    break  down  in 
trying.     It  is  the  old  Anglo-Saxon  plan  to  find  out  wdiat 
can  be  done  by  over-doing,  and  so  learning  the  extreme 
limit.     A  butcher's  boy  was  spokesman  for  his  race,  when 
summoned  before  the  magistrates  at  Teddington,  for  furi- 
ous  driving  ;  the   constable  stated    the   mare  was  going 
thirteen   miles  an   hour,   w^hen  the  boy   triumphantly  re- 
futed him  by  saying, — "  She  can't  do  it  ;  she  has  not  got 
it  in  her  !  "     He  evidently  knew  to  a  nicety  what  she  could 
do,  by  noting  what  she  could  not  do.      So  it  is  in  the  pres- 
ent pace  of  life.     It  is  faster  !   faster  !    Our  steeplechasers 
gallop  faster  than  their  old-fashioned  half-bred  predeces- 
sors ;    our   fox-hounds   run   faster  than    of    yore,   till  our 
hunters    have   to   be  nearly  thorough-bred  to  keep  pace 
with  them.     It  is  the  pace  at   which  we  live    that  over- 
taxes our  organic  processes,  and  the  digestive  processes 


CHAP.  VI.]         SECONDARY  INDIGESTION.  101 

breaking  down  under  the  strain.  It  is  the  early  period 
at  which  the  pace  is  put  on  which  is  telling.  Our  race- 
horses are  trained  so  young,  that  they  soon  are  unfit  for 
the  racecourse  ;  how  few  horses  are  there  now  who  are 
good  for  anything  at  six  years  old.  Old  Forrester  was 
racing  long  years  after  any  horse  is  now  put  to  the  stud; 
but  probably  he  never  ran  as  a  two-year  old.  Eclipse  was 
five  years  old  before  he  was  trained.  As  with  horses,  so  with 
men.  A  man  used  to  be  satisfied  to  have  earned  a  compe- 
tency at  60;  now  he  strains  to  retire  at  45  with  a  fortune. 
As  with  men,  so  with  the  racehorses;  the  difficulty  is  to  keep 
up  their  appetite  and  digestion.  This  it  is  which  bothers 
the  trainer.  The  young  horses  "  go  off  their  feed,"  and  then 
the  training  is  suspended.  Quinine,  with  acids  and  gen- 
tian, is  in  vogue  in  trainers'  establishments,  to  keep  up 
the  young  scions  of  a  famous  stock.  In  the  high-bred 
racer,  the  digestive  organs  give  way  under  the  demands 
upon  them,  made  too  early.  As  the  trainer  has  to  whip 
up  the  appetite  of  his  two-year  old,  so  the  Lincolnshire 
grazier  finds  it  pay  him  to  cook  a  part  of  the  food  for 
his  stall-fatted  stock.  Perhaps  in  a  few  years  it  may  be 
necessary,  or  anyhow,  profitable,  to  give  these  oxen  tonics. 
To  what  then  are  we  coming.  Tonics,  artificial  digestive 
agents,  or  even  artificially  digested  food,  may  be  palliative 
as  regards  the  individual:  but  they  cannot  be  regarded  as 
curative  as  to  the  race.  For  our  successors  something 
else  is  necessary  ;  and  what  that  "  something "  must  be 
will  be  seen  in  a  subsequent  chapter. 

There  is  another  aspect  of  this  subject,  of  the  effect  of 
mental  attitudes  upon  the  organic  processes,  which  needs 


102  SECONDARY  INDIGESTION:  [chap.  vi. 


a  little  consideration,  especially  for  those  whom  it  con- 
cerns, viz.,  the  hypochondriac  ;  and  those  who  though  not 
exactly  belonging  to  the  class  "  malade  imaginaire,"  still 
give  too  much  attention  to  their  subjective  sensations.  It 
may  be  well  again  to  quote  Dr.  Carpenter  verbatim  in 
this  matter: — 

"  The  influence  of  the  state  of  expectant  attention  in 
modifying  the  processes  of  nutrition  and  secretion,  is  not 
less  remarkable  than  we  have  seen  it  to  be  in  the  produc- 
tion of  muscular  movements.     The  volitional  direction  of 
the  co7isciousness  to  a  part,  independently  of  emotional  ex- 
citement, suffices  to  call  forth  sensations  in  it,  which  seem 
to  depend  upon  a  change  in  its  circulation  ;  and  if  this 
state  be  kept  up  automatically  by  the  attraction  of  the 
attention,  the  change  may  become  a  source  of  modification, 
not  only  in  the  functional  action,  but  in  the  nutrition   of 
the  part.     Thus,  there  can  be  no  doubt  that  real  disease 
often  supervenes  upon  fancied  ailment,  especially  through 
the  indulgence  of  what  is  known  as  the  hypocliondriacal 
tendency  to  dwell  upon  uneasy  sensations  ;  those  sensa- 
tions being  themselves,  in  many  instances,  purely  '  sub- 
jective.'    In  many  individuals  (especially  females),  whose 
sympathies  are  strong,  a  pain  in  any  part  of  the  body  may 
be  produced  by  witnessing  it  in  another,  or  even  hearing 
described  the  sufferings  occasioned  by  disease   or  injury 
of  that  part  ;   and  if   this  pain  be  attended  to,  and   be- 
lieved in,  as  an  indication  of  serious  mischief,  injurious 
consequences   are   very  likely  to   follow.      So,  again,   the 
self-tormenting  hypochondriac   will  imagine   himself  the 
victim  of  any  malady  that  he  may  '  fancy  ; '   and  if  this 


CH.u'.  Yi.]         SECONDARY  mDIGESTIOIT.  103 

fancy  should  be  sufBciently  persistent  and  engrossing,  it 
is  not  unlikely  to  lead  to  real  disease  of  the  organ  to  which 
it  relates.  His  persistent  direction  of  the  attention  has  a 
much  greater  potency,  when  combined  with  the  expectation 
of  a  particular  result;  and  thus  it  happens  that  the  spells 
of  pretenders  to  occult  powers,  in  all  ages  and  nations, 
often  produce  the  predicted  maladies  in  the  subjects  who 
are  credulous  enough  to  believe  in  their  efficacy.  Such  was 
formerly  the  case  among  the  negroes  of  the  British  West 
Indies,  to  such  a  degree,  that  it  was  found  necessary  to 
repress  what  was  known  as  ^  Obeah  practices,'  by  penal 
legislation;  a  slow  pining  away,  ending  in  death^  being  the 
not  uncommon  result  of  the  fixed  belief  on  the  part  of  the 
victim,  that  '  obi '  have  been  put  upon  him  by  some  old 
man  or  woman  reported  to  possess  the  injurious  power. 
So  great,  indeed,  was  the  dread  of  these  spells,  that  the 
mere  threat  of  one  party  to  a  quarrel  to  ^put  obi'  upon 
the  other,  was  often  sufficient  to  terrify  the  latter  into 
submission.  And  there  is  adequate  ground  for  the  asser- 
tion, that  even  amongst  the  better  instructed  classes  of 
our  own  country,  a  fixed  belief  that  a  mortal  disease  had 
seized  upon  their  frame,  or  that  a  particular  operation  or 
system  of  treatment  would  prove  unsuccessful,  has  been 
in  numerous  instances,  the  real  occasion  of  a  fatal  result." 
I  introduce  this  paragraph  verbatim,  to  put  the  dys- 
peptic on  his  guard  about  the  study  of  his  subjective 
sensations;  as  much  as  to  warn  the  hypochondriac  that 
it  is  well  to  try  to  put  away  his,  or  her  morbid  dwelling 
on  ideal  conditions.  It  is  clear  that  it  is  desirable  the 
dyspeptic  be  cured  as  soon  as  may  he;    not  only  fpr  his,  or 


104  SECONDARY  INDIGESTION.         [chap.  yi. 

her  comfort  or  well  being,  but  iii  order  to  obviate  the 
danger  of  disordered  function  leading  to  structural  change 
from  the  direction  of  the  attention  thereto.  This  is  no 
imaginary  danger,  as  Dr.  Carpenter  shews.  Even  when 
the  sensations  of  discomfort  are  present,  it  is  well  not  to 
let  them  absorb  the  attention;  the  sufferers  should  turn 
their  thoughts  in  other  directions,  or  have  them  distracted 
for  them.  Certainly  it  is  within  my  personal  experience 
that  persons  who  have  long  been  troubled  with  indigestion, 
have  died  of  cancer  of  the  stomach.  Nor  do  I  regard  these 
as  accidental  relationships,  or  mere  coincidences.  Long 
gastric  trouble  culminated  in  cancer  of  the  pyloric  ring, 
not  that  such  is  a  common  occurrence;  but  certainly  in 
a  number  of  cases  either  gastric  cancer  had  a  far  reaching 
history  of  indigestion  preceding  it;  or  long-standing  func- 
tional disorder  led  to  structural  change:  whichever  way 
the  reader  chooses  to  put  it. 

It  is  most  desirable  then  that  such  sensations  as  arise 
from  disordered  function,  are  put  away  as  much  as  possible 
by  actual  sufferers;  while  those  whose  maladies  are  cen- 
tric, and  due  rather  to  disturbance  within  the  posterior 
lobes  of  the  cerebral  hemispheres,  than  to  actual  disorder 
in  the  viscera,  will  be  wise  to  attend  as  little  as  they 
can  to  their  abnormal  feelings.  Dr.  Hughlings  Jackson, 
F.R.C.P.,  holds  that  the  liver,  indeed,  each  of  the  viscera, 
has  its  representative  area  in  the  brain,  just  as  much  as  the 
arm  or  leg  is  represented  in  a  distinct  and  localized  area. 
The  hypochondriac  feels  his  sensations  in  the  part  to 
which  he  refers  them;  just  as  other  sensations  are  ex- 
perienced which  are  unreal.     The  lunatic  is  not  the  only 


CHAP.  VI.]         SECONDARY  INBIGESTIOX.  105 

individual  who  has  what  others  regard  as  hallucinations. 
What  each  one  feels  is  known  to  himself.  A  patient  of 
mine  once  felt  hairs  in  liis  mouth;  there  were  no  such 
hairs.  But  the  impression  lasted  the  remainder  of  his 
lifetime.  Jn  such  a  case,  there  must  have  been  a  centric 
disturbance  referred  to  a  peripheral  cause,  in  accordance 
with  our  common  experience.  "  Phantom  limbs,"  are  a 
not  uncommon  phenomena;  and  a  man  will  feel  the  little 
finger  ache  with  cold,  in  an  arm  amputated  years  before. 
So  in  hypochondriasis,  probably  the  disturbance  is  the 
primitive  sensation  in  the  cerebral  area,  not  the  part  to 
which  it  is  referred;  but  the  persistent  direction  of  the  at- 
tention to  the  said  viscus,  may  in  time  lead  to  actual  func- 
tional disorder;  which  in  its  turn  may  set  up  structural 
change  in  the  course  of  time. 

The  relations  betwdxt  the  brain  and  the  digestive  organs 
are  intimate  and  interesting.  Disturbances  in  the  viscera 
disorder  the  brain  directly,  as  well  as  by  the  abnormal 
products  which  reach  it  through  the  blood.  Disturbance 
in  the  posterior  lobes,  those  portions  of  the  hemispheres 
connected  with  our  internal  sensations,  may  lead  in  time 
to  disorder  in  the  viscera  associated  therewith.  The  direc- 
tion of  the  attention  operates  banefully  upon  the  organs 
to  which  it  is  turned.  There  are  actions  and  reactions 
within  the  complex  microcosm;  and  the  organic  nervous 
system  has  not  been  denominated  "  the  sympathetic  "  with- 
out good  and  sufficient  reasons.  This  is  an  aspect  of  the 
subject  which  must  be  considered  and  reflected  upon.  Its 
consideration  may  be  disturbing  to  sundry  nervous  per- 
sons; but  that  is  simply  unavoidable,  however  undesirable. 


106  SECONDARY  INDIGESTION.  [chap.  vi. 

It  is  all  very  well  for  certain  enthusiastic  individuals  to 
deny  themselves  wine,  which  would  do  them  good,  in  order 
to  set  an  example  of  abstinence  to  those  who  yield  to  al- 
coholic temptation;  but  the  bulk  of  humanity  do  not 
carry  their  "  altruism  "  to  such  lengths.  Such  a  way  of 
regarding  the  linked  intimacy  of  mental  states  and  morbid 
digestive  processes,  may  be  alarming  to  sundry  invalids 
and  valetudinarians,  but  its  consideration  will  be  benefi- 
cial to  a  large  class;  and  after  all,  Jeremy  Bentham  was 
right,  when  he  insisted  upon  "  the  happiness  of  the  greatest 
number"  being  the  thing  to  be  aimed  at.  For  on  the 
other  hand,  a  mental  state  may  operate  beneficially. 

Dr.  Carpenter  continues — 

"  But  on  the  other  hand,  the  same  mental  state  may 
operate  beneficially,  in  checking  a  morbid  action  and 
restoring  the  healthy  state.  That  the  confident  expectation 
of  a  cure  is  the  ipost  potent  means  of  bringing  it  about, 
doing  that  which  no  medical  treatment  can  accomplish, 
may  be  affirmed  as  the  generalized  result  of  experiences 
of  the  most  varied  kind,  extending-  throuo^h  a  lono-  series 
of  ages."  He  then  instances  cases  of  "cures"  ejBfected 
by  faith,  and  says, — "For  although  there  can  be  no  doubt 
that  in  a  great  number  of  cases  the  patients  have  believed 
themselves  to  be  cured,  when  no  reed  ameliorcition  of  their 
condition  had  taken  place,  yet  there  is  a  large  body  of 
trustworthy  evidence,  that  permanent  amendment  of  a 
kind  perfectly  obvious  to  others,  has  shown  itself  in  a 
great  variety  of  local  maladies  when  the  patients  have 
been  sufficiently  possessed  by  the  expectation  of  benefit, 
and  h  J  faith  in  the  efficacy  of  the  means  employed."     It 


cH.\p.  VI.]       seco:n'dary  indigestion:  io7 

is  quite  clear  in  this  matter,  that  the  confidence  of  the 
patients  will  rest  upon  the  confidence  with  which  they 
are  told  that  they  will  be  cured.  If  the  curer,  or  tliauma- 
turgus,  believe  not  in  the  cure,  he  cannot  inspire  the 
patient  with  faith.  If  the  medical  man  speak  to  the 
patient  with  doubtful  accents  and  hesitating  utterances, 
he  does  not  inspire  confidence  ;  he  really  sows  distrust. 
This  is  the  explanation  of  the  successful  treatment  of  a 
case  by  one  man,  where  another  has  failed;  the  remedial 
measures  being  much  the  same.  The  one  carries  the 
patient  with  him  to  the  restoration  of  health  ;  the  other 
intensifies  a  morbid  state,  and  tends  to  make  it  permanent. 
This  is  a  matter  too  little  thought  about.  Just  as  a 
weak-willed  medical  man  fails  to  do  certain  patients  good  ; 
and  lack  of  decision  of  character  unfits  a  medical  man  for 
dealing  with  emergencies,  where  the  judgment  must  be 
prompt  and  the  action  energetic  ;  so  the  therapeutic  ni- 
hilist, who  doubts  the  eflBcacy  of  drugs,  and  leaves  the 
patient  to  nature,  disheartens  many  patients,  and  leaves 
them  chronic  valetudinarians,  when  in  the  hands  of  an 
enthusiast,  the  cases  would  soon  move  onward  to  a  satisfac- 
tory termination.  There  are  some  men  who  are  "  doubt- 
inor  Thomases  :"  there  are  others  who  decrv  what  thev  do 
not  understand,  and  depreciate  remedies  with  whose  po- 
tency they  are  unacquainted,  who  do  infinite,  immeasurable 
harm  to  their  patients.  An  eclipse  of  faith  in  medicines 
has  now  existed  some  time  ;  but  the  darkness  is  beginning 
to  move  away,  and  a  return  of  faith,  stronger,  firmer,  more 
capable  of  giving  a  raison  d'etre  for  its  existence  than  in 
the  past,  is  dawning, — the  daybreak  of  happier  times  for 


108  SECONDARY  mDIGESTION.          [chap.  yi. 

those  who  are  stjicken  down  with  ilhiess,  or  crippled  in 
their  working  power  by  incapacity  in  their  digestive  viscera. 
This  therapeutic  nihilism  is  a  passing  wave  of  opinion,  a 
temporary  mental  state,  the  end  of  which  is  at  hand;  and 
the  sooner  it  is  over  the  better  for  all.  The  patient's  pros- 
pects will  be  all  the  brighter,  the  medical  man  all  the 
happier  for  feeling  that  the  patient  has  got  some  "  value 
received  "  in  return  for  his  outlay.  A  healthier  condition 
of  thought  on  matters  medical  will  generally  obtain  ;  for 
quacks,  charlatans,  and  irregular  practitioners  of  all  kinds, 
are  to  a  great  extent  fostered  by  the  recent  want  of  faith 
in  the  medical  profession.  When  a  man  is  sick,  what  he 
wishes  is  to  get  well  ;  the  means  is  to  him  a  matter  of 
comparative  indifference.  If  he  gets  his  health  again,  he 
recks  little  whether  it  is  by  the  means  of  a  notorious  quack, 
or  by  those  of  some  one  possessed  of  the  "  hall  mark  "  of 
the  venerable  College  of  Physicians. 

This  is  a  moral  aspect  of  the  question  which  that  ancient 
institution  has  been  rather  nodding  over  for  some  years 
past  ;  and  it  is  quite  time  that  it  awakened  up  to  a  proper 
consideration  of  the  subject.  The  public  will  not  rest 
patiently  quiet  till  its  slumbers  are  completed  ;  and  the 
sooner  the  period  of  awakening  arrives  the  better  for  all. 
Stronger  faith  in  the  profession  as  a  body,  will  lead  to 
more  belief  in  the  individual  units  of  it  ;  and  this  in  turn 
will  inspire  the  public.  Perhaps  those  acrid  personages 
who  have  a  distinct  line  of  faith,  or  rather  the  want  of 
it,  those  individuals  who  believe  in  Homoeopathy,  and  talk 
flippantly  of  "Allopaths,"  who  deny  the  utility  of  the 
Contagious  Diseases  Act   (Human),   who   are   anti-vacci- 


CHAP.  VI.]         SECONDARY  INDIGESTION.  109 

iiators  ;  who  are  blended  compounds  of  scepticism  and 
credulousness  ;  those  who  are  utterly  unteachable  from 
prejudice  and  ignorance  "  vaunting  itself  as  knowledge," 
cannot  be  benefited  ;  not  even  if  their  chief  diurnal  in- 
structor, their  *'  guide,  philosopher,  and  friend,"  the  Daily 
JVews,  was  to  modify  its  attitude,  and  shew  a  livelier  in- 
terest in  matters  affecting  the  public  health,  and  a  little 
more  decent  respect  for  the  observations  of  "  the  natural 
man,"  They  are  an  unhopeful  class,  the  obstructionists 
of  all  progress  in  matters  sanitary  and  hygienic  ;  wdiose 
self-satisfaction  in  their  ignorance  on  matters  medical  is 
simply  as  aggressive  and  impertinent  as  that  ignorance 
is  appalling.  They  are  blinded  guides  in  their  self-ap- 
pointed mission  of  directing  the  opinions  of  mankind  ;  but 
their  faith  in  themselv^es  is  unbounded  ! 

Such  then  are  the  cerebral  relations  of  disturbances  in 
the  digestive  processes.  They  do  not  necessarily  involve 
a  disordered  tongue,  or  constipation,  or  diarrhoea ;  or 
manifest  those  evidences  of  dyspepsia,  found  when  the 
indigestion  is  primary. 

There  is  another  form  of  indis^estion  due  to  nervous  dis- 
turbance  elsewhere,  which  also  carries  with  it  no  obvious 
siofns  of  the  dio-estive  tract  beino-  the  sole  seat  of  trouble,  as 
a  bare,  or  raw^,  or  a  foul,  or  furred  tongue  ;  but  w^iere  con- 
stipation is  commonly  found.  This  is  due  to  a  tender  ovary, 
mostly  the  left.  This  lies  near  the  rectum,  and  the  pas- 
sage of  fasces  causes  pain  ;  the  pain  inhibits  the  movements 
of  the  bowel,  and  constipation  is  the  result.  The  accu- 
mulated ffeces  keep  up  the  ovarian  tenderness,  and  the 
voiding  of  them  produces  still  more  pain.    And  so  the  action 


110  SECONDARY  mDIGESTIOK         [chap.  vi. 

and  reaction  work  in  a  downward  direction.  Such  indi- 
gestion is  properly  termed  "  reflex."  It  is  a  very  common 
malady  which  has  been  overlooked.  It  is  mentioned  by 
Negrier,  Robert  Barnes,  and  Lombe  Atthill.  I  had  to 
learn  to  decipher  it  for  myself,  and  first  described  it  in  an 
article  on  "  Ovarian  Dyspepsia,"  in  the  American  Journal 
of  Obstetrics  and  Diseases  of  Women  and  Children^  Jan., 
1878,  though  it  may  have  been  delineated  elsewhere  j  but 
if  so,  I  am  not  acquainted  with  the  article. 

"  The  reproductive  organs  of  woman  are  the  source  of 
most  of  her  troubles  during  that  period  of  her  life  when 
they  are  functionally  active.  Often  will  far-away  irritation 
in  the  womb,  or  ovary,  be  found  to  be  the  cause  of  the  moot 
prominent  objective  and  subjective  phenomena  manifested 
elsewhere.  Irritation  is  not  always  felt  where  it  arises  ; 
the  pain  is  very  commonly  in  the  knee  when  the  disease  is 
in  the  hip-joint  ;  in  the  right  shoulder  when  the  liver  is 
involved.  We  know  that  the  pregnant  uterus,  especially 
in  the  early  months  before  it  has  escaped  from  the  pelvis, 
commonly  produces  very  troublesome  vomiting  ;  or  it  may 
produce  a  persistent  cough,  known  in  Scotland  as  '  a 
cradle  cough.'  Vomiting  is  a  common  outcome  of  injury  to, 
or  acute  mischief  in  the  testicle,  as  it  is  a  pronounced  symp- 
tom of  a  calculus  in  the  kidney.  The  old  term  '  the  sym- 
pathetic nerve  '  was  founded  on  the  appreciation  of  the  fact 
that  one  part  was  influenced  by,  or  sympathized  with,  an- 
other through  the  fibrils  of  this  nerve.  Currents  may  arise 
in  the  ovary  and  be  felt — not  there  when  they  arise — but 
at  some  far-distant  point,  where  they  run  out.  If  a  num- 
ber of  ivory  balls  be  suspended  in  a  row,  touching  each 


CHAP.  VI.]       .  SECONDARY  IKDIGESTIOK.  Ill 

other,  and  a  tap  be  given  to  either  terminal  ball,  it  is  the 
one  at  the  otlier  end  which  flies  from  its  place.  Conse- 
quently waves  of  nerve-perturbation,  arising  in  the  ovary, 
manifest  themselves  by  disturbances  elsewhere.  The  glit- 
tering flash  which  glances  out  from  some  female  irides  is 
the  external  indication  of  ovarian  irritation,  and  '  the 
ovarian  gleam '  has  features  quite  its  own.  The  most 
marked  instance  which  ever  came  under  my  notice  was  due 
to  irritation  in  the  ovaries,  which  had  been  forced  down  in 
front  of  the  uterus  and  been  fixed  there  by  adhesions. 
Here  there  was  little  sexual  proclivity,  but  the  eyes  were 
very  remarkable.  They  flashed  and  glittered  unceasingly, 
and  at  times  perfect  lightning  bolts  shot  from  them. 
Usually  there  is  a  bright  glittering  sheen  in  them  which 
contrasts  with  the  dead  look  in  the  irides  of  sexual  excess, 
or  profuse  uterine  discharges.  Cough,  palpitation,  face  • 
ache,  usually  on  the  right  side,  inframammary  pain, 
usually  in  the  left  sixth  or  seventh  intercostal  nerves,  and 
gastric  irritation  are  the  ordinary  outcomes  of  uterine  flex- 
ion, or  ovarian  disturbance.  The  most  important  matters 
clinically  are  the  gastric  symptoms  reflexly  excited  by 
pelvic  irritation. 

"  So  important  and  so  common  are  these  maladies,  and 
so  utterly  unsatisfactory  their  treatment  under  the  usual 
remedies — as  bismuth,  hydrocyanic  acid,  oxide  of  silver, 
&c. — that  they  deserve  to  be  treated  at  some  length. 
In  the  first  place  the  stomach  has  different  nerve-fibrils — 
those  from  the  vagus,  and  those  from  the  sympathetic. 
Claude  Bernard  observed  that  the  application  of  a  galvanic 
stimulus  to  the  vasrus  fibres  caused  free  secretion  of  the 


112  SECONDARY  INDIGESTION.         [chap.  ti. 


gastric  juice  ;  while  the  same  stimulus  applied  to  the 
sympathetic  fibrils  issuing  from  the  semi-lunar  ganglia, 
caused  a  diminution  and  complete  arrest  of  the  secretion. 
The  action  of  sympathetic  nerve-fibrils  is  to  excite  con- 
traction in  the  arteries  and  arterioles  ;  that  of  the  pneumo- 
gastric  fibrils  to  dilate  these  vessels.  Consequently  we  can 
readily  understand  how  currents  coming  in  by  the  sympa- 
thetic tracts  from  pelvic,  or  other  irritation,  may  contract 
the  gastric  arterioles  and  arrest  the  flow  of  gastric  juice. 
If  the  irritation  be  sufficiently  powerful  then  vomiting  is 
set  up.  In  ordinary  digestion  the  gastric  blood-vessels 
are  dilated  and  there  is  a  free  flow  of  gastric  juice.  The 
irritation  coming  in  from  without  checks  both  these  pro- 
cesses, and  then  imperfect  digestion  with  pain,  or  nausea 
is  the  result.  This  may  not  proceed  further  than  loss  of 
appetite,  dyspepsia,  and  nausea  :  or  there  may  be  severe 
persistent  vomiting  set  up  by  the  introduction  of  food  into 
the  stomach,  till  a  very  serious  condition  may  be  reached. 
In  either  case  the  tongue  is  clean,  and  there  are  no  evi- 
dences of  disturbance  in  the  gastro-intestinal  canal,  as  in 
primary  gastric  indigestion.  Such  is  the  dyspepsia  so 
common  in  women.  Primary  dyspepsia  is  no  more  fre- 
quent in  women  than  in  men,  and  presents  the  same 
features  in  both  sexes.  But  reflex  dyspepsia  has  other 
and  quite  different  associations.  In  both  forms  of  dyspep- 
sia there  may  be  constipation,  or  diarrhcBa,  excited  by  the 
undio-ested  food  irritating  the  intestines,  but  these  are 
incidental  or  coincident  collaterals.  In  reflex  dyspepsia 
there  are  usually  the  intercostal  neuralgia,  with  the  three 
tender  spots  of  Valleix,  one  under  the  mamma,  the  second 


CHAP.  Yi.]  SECONDARY  INDIGESTION.  113 

at  the  base  of  the  left  scapula,  the  third  at  the  exit  of  the 
posterior  rootlet  of  the  sixth  or  seventh  intercostal  nerve 
from  the  spinal  column;  and  palpitation.  Less  commonly 
faceache  or  cough,  and  in  middle-aged  women  flushings. 
Then  there  are  the  uterine  out-comes  of  the  ovarian  mis- 
chief— leucorrhoea,  with  or  without  menorrhagia,  while  at 
times  the  menstrual  flux  is  lost,  or  all  but  lost,  in  the  j^ro- 
f  use  leucorrhoea.  The  o-enerative  or^-ans  of  women  become 
turgid  with  blood  during  sexual  excitement,  approaching 
the  erectile  condition  of  the  male  organ  under  excitement. 
Ovarian  irritation  sets  up  vascular  turgescence  in  the  fe- 
male parts  which  continues  more  or  less  persistingly.  The 
consequence  is  that  there  is  profuse  secretion,  often  with  ex- 
cessive catamenial  losses.  Frequently,  too,  there  are  erotic 
dreams,  recurrent  orgasms,  during  sleep,  '  the  period  ^:)a;* 
€xcelle?ice  of  reflex  excitability.'  In  more  pronounced  cases, 
these  discharges  take  place  in  the  waking  state,  without 
any  reference  to  psychical  conditions,  being  found  alike  in 
married  women  cohabiting  with  their  husbands,  and  in 
spinsters  and  widows.  That  sexual  excitement  may  be 
produced,  or  kept  up  by  lewd  thought  may  not  be  denied; 
but  this  is  not  necessarily  the  psychical  attitude  here. 
The  uterine  centres  in- the  cord  and  the  centres  presiding 
over  the  bladder  lie  in  close  proximity  to  each  other.  The 
irritable  condition  of  the  lumbar  centres  of  the  reproduc- 
tive organs  is  communicated  to  the  vesical  centres,  and 
then  a  very  distressing  condition  results,  viz.,  a  state  of 
weakness  and  irritability  in  the  bladder,  and  the  call  to 
make^water  is  sudden  and  imperative,  and  must  be  attended 
to  at  once,  or  a  certain  penalty  be  paid  for  non-attention. 


114  SECONDARY  INDIGESTION.          [cHAr.  vi. 

Such  are  the  objective  and  subjective  phenomena  exhibited 
in  a  complete  case  of  'reflex  dyspepsia'  of  ovarian  origin: 
and  it  is  by  the  study  of  such  well-marked  cases  that  the 
student  will  learn  to  recognize  the  less  marked  or  imperfect 
cases.  Nor  does  it  necessarily  follow  that  the  symptoms 
shall  stand  in  a  definite  proportion  to  each  other  in  each 
and  every  case.  Sometimes  the  chief  disturbance  is  ute- 
rine, at  other  times  mainly  gastric.  When  the  latter,  the 
case  often  runs  as  follows — a  girl,  usually  of  the  neurosal 
diathesis,  betwixt  nineteen  and  twenty -four  years  of  age, 
becomes  the  subject  of  intractable  vomiting.  This  goes  on 
till  such  weakness  is  produced  that  the  patient  is  confined 
to  bed,  and  her  life  apparently  endangered.  The  least 
particle  of  food  is  immediately  rejected,  more  or  less  com- 
pletely. All  sorts  of  combinations  of  drugs  are  tried,  and 
fail  to  procure  any  alleviation  of  the  condition.  The  medi- 
cal attendant  is  nearly  worried  out  of  his  life,  consultants 
are  called  in  without  avail;  the  friends  of  the  patient  are 
worked  up  to  a  state  of  feverish  anxiety;  the  sufferings  of 
the  patient  are  not  inconsiderable;  and  so  the  case  wears 
on  for  weeks.  Bismuth,  hydroc^^anic  acid,  opium,  effer- 
vescing mixtures,  champage,  milk  and  seltzer  water,  beef- 
tea,  hot  and  cold,  raw  meat  pounded,  maltine,  all  are  tried 
and  fail;  sometimes  enough  is  retained  to  support  life;  at 
other  times  it  becomes  necessary  to  resort  to  nutritive  ene- 
mata.  All  who  have  seen  much  practice  are  familiar  with 
such  cases,  which  are  very  trying  to  all  parties  concerned, 
and  which  are  unaffected  by  the  different  remedial  measures 
resorted  to;  and  which  seem  at  last  to  wear  themselves  out, 
and  are  followed  by  long  and  tedious  convalescence.     A 


CHAP.  VI.]         SECONDARY  INDIGESTION.  115 


year  or  two  afterwards  the  patient  is  in  good  health,  often 
a  happy  mother.  Here  the  absence  of  local  indications 
throws  the  medical  man  off  the  scent  as  to  the  real  nature 
of  the  malady  with  which  he  is  brought  in  contact,  and  the 
ovaries  are  unsuspected.  All  the  remedies  are  futile  and 
inoperative  because  not  directed  to  the  origin  of  the  trou- 
ble. The  case  lingers  on  till  it  would  seem  the  general 
mal-nutrition  starves  down  the  congested  ovary  into 
quietude,  and  then  the  reflex  disturbances  cease.  Were 
the  true  origin  of  the  case  known  or  discovered,  then  the 
successful  treatment  would  soon  be  forthcominof-.  As  a 
case  in  point,  I  may  mention  a  girl  who  came  under  my 
care  some  time  ago  at  the  West  London  Hospital.  For 
many  months  she  had  been  under  medical  treatment  for 
persisting  retching  and  vomiting.  The  girl  was  pale  and 
anasmic,  with  lack-lustre  eyes,  and  a  peculiar  but  charac- 
teristic expression,  which  may  be  observed  but  cannot  be 
described,  indicative  of  ovarian  trouble.  The  left  ovary 
was  found  congested  and  exquisitely  tender,  pressure  over 
it  almost  producing  syncope,  and  exciting  acute  nausea. 
The  ovary  was  treated,  and  in  ten  days  the  girl  left  the 
Hospital — well,  but  I  doubt  if  permanently  cured. 

"What  is  the  treatment  of  these  cases?  It  consists  of 
several  factors  each  essential  and  complementary  to  the 
others.  The  bowels  should  be  unloaded,  so  that  there 
shall  be  no  pelvic  congestion.  A  small  quantity  of  sul- 
phate of  magnesia  in  each  dose  of  medicine  will  usually 
attain  this  end.  If  not  quite  sufficient  an  aloetic  pill  at 
bed-time  is  indicated.  In  small  doses,  as  said  before,  aloes 
excites  the  hremorrhoidal  vessels;  in  fuller  doses  it  depletes 


116  SECONDARY  INDIGESTION.  [chap.  vi. 

them.  The  bowels  should  be  emptied  at  bed-time.  A 
load  in  the  bowels  during  sleep  produces  vascular  turges- 
cence  in  females  whose  reproductive  organs  are  out  of 
health,  just  as  it  produces  chordee  in  a  man  with  gonor- 
rhoea. Then  comes  the  other  factor — the  reflex  manifesta- 
tions. Instead  of  treating  the  stomach  an  agent  must  be 
o:iven  which  will  influence  the  nerve  tracts  over  which  the 
perturbatory  waves  travel.  Bromide  of  potassium  deadens 
the  nerve-fibrils  alike  along  their  course  and  at  their  peri- 
pheral endings.  Both  at  the  ^periphery  in  the  ovary  and 
at  the  terminus,  the  stomach,  is  its  influence  felt.  It 
blunts  the  nerve  endings  while  it  deadens  the  conductive 
power  of  nerve-fibrils.  Consequently  a  combination  like 
the  following  is  useful' : — 

Mag.  Sulph.  3  i. 

Potass.  Bromidi  3i. 

Mist.  Camphorse,    |  i.,  ter  in  die. 

If  the  stomach  reject  this  a  hypodermic  injection  of  half, 
or  a  third,  of  a  grain  of  morphia  will  usually  produce  such 
effects  that  the  stomach  will  tolerate  the  medicines. 
Nutritive  enemata  may  be  needed  for  a  day  or  two.  As 
soon  as  the  bromide  is  tolerated  and  retained,  matters 
improve.  Sometimes  it  is  well  to  substitute  infusions  of 
gentian  for  the  camphor  mixture  as  a  vehicle;  it  acts 
beneficially  upon  the  stomach,  as  do  all  bitters,  and  ren- 
ders it  more  tolerant  of  the  medicines.  Local  treatment 
in  the  shape  of  a  blister  over  the  tender  ovary  is  of  much 
value;  not  only  does  it  produce  a  mental  impression,  but 
we  have  reason  to  suppose  that  nerve-waves  can  meet  and 


CHAP.  VI.]         SEC Om) ART  IXBIGESTIOy.  Ill 

neutralize  each  other — like  rays  of  light — under  certain 
circumstances.  The  ordinary  Emplastrum  Cantharidis 
2x2  applied  over  the  offending  ovary  on  going  to  bed 
will  usually  be  found  to  produce  vesication  by  the  morning. 
Some  slio:ht  soreness  follows,  but  the  relief  afforded  to  the 
internal  pain  far  outweighs  this.  In  some  rare  instances 
a  crop  of  boils  follows  the  blister;  but  so  rarely  as  not  to 
militate  a2:ainst  its  use.  By  these  measures  combined, 
the  reflex  g-astric  disturbance  is  effectually  removed. 

"  There  remains  the  leucorrhceal  loss  to  be  considered. 
Hiofofinson's  svrino-e,  or  the  common  enema  svrinofe  for 
infants,  are  preferable  to  the  glass  syringe,  which  is  brit- 
tle, and  accidents  sometimes  occur.  First  an  injection 
of  plain  water  to  remove  all  discharge,  and  then  of  a  little 
alum  water,  not  stronger  than  an  ounce  to  two  quarts  of 
water,  will  usually  soon  reduce  the  loss.  If  there  also  be 
menorrhagia  the  usual  measures  must  be  adopted."  [T7ie 
Practitioner's  JSandbooh  of  Treatment^  2nd  edition.) 

Another  form  of  "  secondary  indigestion,"  is  that  due  to 
venous  fulness  from  valvular  disease  of  the  heart.  Its  chief 
indication  is  that  "sense  of  fulness"  experienced  by  the 
patient,  even  when  the  stomach  is  empty  of  food.  This  is 
rarely  absent  in  cases  of  cardiac  failure  in  elderly  persons, 
indeed,  it  is  in  old  persons  that  it  is  mainly  felt;  though  it  is 
not  uncommon  in  young  persons  with  severe  mitral  disease. 
It  arises  from  obstruction  to  the  circulation,  due  to  some 
lesion  in  the  heart — usually  a  valvular  lesion;  but  at  times 
occasioned  bv  the  vieldino-  of  the  muscular  wall.  This  ob- 
struction  causes  a  damming  of  the  blood  at  the  point,  which 
works  backwards  into  the  veins  and  venules. 


118  SECONDARY  INDIGESTION:         [chap.  vi. 

"  Sooner  or  later,  the  right  heart  yields,  either  by  the 
tricuspid  ostium  becoming  so  large  as  the  muscular  "walls 
dilate,  that  the  valves  become  insufficient;  or  by  secondary 
implication  of  the  tricuspid  valves  rendering  them  no  longer 
equal  to  the  closure  of  the  normal  ostium;  or  by  a  combina- 
tion of  both.  Then  the  venee  cavse  become  distended,  and 
the  jugular  veins  are  seen  to  pulsate.  Some  jugular  pulsa- 
tion may  be  seen  before  the  tricuspid  becomes  insufficient; 
it  is  caused  by  the  reflux  of  blood  through  the  tricuspid  be- 
fore its  flaps  are  driven  together  on  the  ventricular  contrac- 
tion. All  the  branches  of  the  venee  cavas  become  distended ; 
and  especially  is  this  the  case  with  the  portal  circulation, 
which  is  not  provided  with  valves.  Splitting  up  as  it  does 
in  the  liver,  the  portal  vein  is  partially  protected  by  minute 
divisions  in  the  liver,  otherwise  great  disturbance  would  be 
occasioned  by  the  want  of  valves  in  it,  on  tricuspid  regurgi- 
tation. But,  in  consequence  of  this  sub-division  in  the 
liver,  that  viscus  becomes  gorged  with  blood  in  tricuspid 
regurgitation,  and  pulsates  with  the  regurgitating  current 
driven  backwards  by  the  hypertrophied  right  ventricle. 
Liver-pulsation  is  a  distinct  symptom  of  diagnostic  value; 
while  the  venous  fulness  of  the  liver  leads  to  a  develop- 
ment of  connective  tissue  corpuscles  in  the  inter-lobular 
areolar  tissue;  first  there  is  increase  of  bulk  in  the  liver, 
then  cirrhosis  or  atrophy  as  the  connective  tissue  con- 
tracts; the  liver  tissue  becoming  much  firmer  and  harder 
than  normal.  The  liver  is  easily  deranged  by  an  excess 
of  food  when  so  affected,  and  great  care  in  diet  is  requisite 
for  the  proper  performance  of  its  functions.  There  is 
serous  effusion  from  the  gorged  venules  into   the   bile- 


cmvp.  VI.]         SECONDARY  INDIGESTION.  119 

passages  attending  it,  so  that  Oppolzer  has  given  to  this 
condition  the  term  '  albuminicholi; '  and  he  further  states 
that  in  this  condition  there  is  consrestion  of  the  mucous 
lining  of  the  bile  ducts  with  jaundice,  and  that  both  these 
conditions  are  readily  affected  by  a  common  cold.  The 
disturbances  and  chan^-es  in  the  liver  are  much  more 
marked  in  some  persons  with  tricuspid  failure  than  in 
others. 

"  The  spleen  is  implicated  in  this  congestion  of  the  portal 
circulation;  it  becomes  enlarged  from  the  development  of 
connective  tissue  in  it,  is  larger  than  normal,  and  of  firmer 
consistence,  resembling  a  beefsteak  in  appearance  when  cut 
open.  We  know,  as  yet,  nothing  of  the  symptoms  of  dis- 
turbance of  the  functions  of  the  spleen. 

"  The  stomach  and  intestinal  canal  are  also  deranged,  and 
the  disturbances  set  up  in  them  by  tricuspid  failure  are  dis- 
tinct and  pronounced.  There  is  fulness  of  the  venules  of 
the  stomach,  and  from  that  springs  catarrh,  with  its  patho- 
gnomonic indication,  *  sense  of  fulness,'  even  when  the 
stomach  is  empty.  The  feeling  of  being  constantly  'too 
full '  is  a  very  common  outcome  of  advanced  cardiac 
failure.  The  secretion  of  gastric  juice  is  impaired,  and  it 
is  diluted  with  a  serous  fluid.  Consequently  its  digestive 
power  is  impaired.  The  catarrhal  mucus  is  readily  folded 
over  any  solid  food,  which  so  covered  cannot  be  acted  upon 
by  the  solvent  juices,  themselves  impaired  in  power.  Dys- 
pepsia is  the  result  of  taking  any  but  liquid  food;  and  this 
condition  of  the  stomach  should  ever  be  borne  in  mind  in 
the  treatment  of  cases  where  the  tricuspid  has  begun  to 
leak.     In  this  condition  of  the  mucous  membrane,  gas  is 


120  SECONDARY  INDIGESTIOIT.         [chap.  vt. 

often  disengaged  very  freely  in  many  elderly  persons,  and 
the  eructations  are  persistent,  and  often  very  loud.  The 
patient's  condition  is  very  distressing;  and  the  pressure  on 
the  diaphragm,  and  on  the  right  ventricle,  causes  much 
disturbance  of  the  respiration  and  dyspnoea,  with  very  un- 
pleasant palpitation.  This  altered  mucous  membrane  also 
causes  morbid  sensations  and  cravings  for  highly-spiced  or 
unsuitable  food;  and  this  may  lead  to  differences  of  opinion 
betwixt  patient  and  doctor. 

"The  intestinal  canal  is  involved,  and  may  be  disturbed  in 
two  directions.  There  may  be  irregular  and  defective  ac- 
tion of  the  bowels  from  imperfect  nutrition  of  the  muscular 
fibre  of  the  bowels,  calling  for  warm  aperient  medicines, — 
(for  here  the  aperients  must  be  warm  and  contain  carmina- 
tives as  much  as  in  the  case  of  the  menopause) — enemata, 
or  soap  suppositories  (Trousseau).  Or  the  congestion  of 
the  venules  of  the  intestinal  canal  may  lead  to  diarrhoea, 
which  often  furnishes  great  relief,  and  should  never  be 
interfered  with  without  good  reason,  nor  until  becoming 
unquestionably  excessive.  King  Chambers  says,  that  in 
conditions  of  gastric  and  intestinal  catarrhs,  the  use  of 
compound  kino  powder  is  indicated,  and  that  under  these 
circumstances,  especially  gastric  catarrh,  it  rarely  consti- 
pates. Alternations  of  constipation  and  of  purging  may 
occur.  Bleeding  piles,  or  hemorrhoids,  are  frequent  in 
the  subjects  of  cardiac  failure.  Hemorrhage  from  these 
piles  often  gives  great  relief,  and  should  not  be  rashly 
checked.  When  no  bleeding  has  occurred  for  some  time,  a 
flow  of  blood  from  some  other  organ  may  take  place,  as 
haemoptysis,  for  instance,  and  be  followed  by  distinct  relief. 


CHAP.  VT.]         SECONDARY  mDIGESTION.  121 

If  there  also  be  old-standing  kidney  disease,  there  may 
be  found  old,  small,  contracted  granular  casts  alongside 
the  dark  recent  casts;  or,  according  to  Basham,  casts 
in  a  state  of  fatty  degeneration.  The  kidneys  are  found 
enlarged,  swollen,  injected  with  blood,  and  from  the  venous 
congestion  a  growth  of  young  connective-tissue  corpuscles 
is  set  up  in  them.  When  attending  the  Pathological  In- 
stitute at  Vienna,  it  Avas  quite  common  to  see  these  recent 
chanor-es  from  heart  failure  alono:side  the  evidences  of  old 
standing  renal  mischief.  The  two  were  quite  distinct. 
This  subject  will  be  treated  more  at  length  in  the  Chapter 
on  the  Gouty  Heart. 

*'  The  genito-urinary  system  is  disturbed  by  the  venous 
congestion.  There  may  be  vesical  catarrh,  prostatic  ful- 
ness, or  urethral  catarrh,  or  even  hydrocele  from  conges- 
tion of  the  pampiniform  plexus  (Oppolzer). 

"  In  women,  there  are  catarrhal  and  menorrhagic  troubles 
from  concrestion  of  the  veins  of  the  uterus  and  vagina. 
Oppolzer  thought  that  profuse  menses  often  accompanied 
the  arterial  fulness  of  aortic  regurgitation,  and  regarded 
it  as  a  symptom  of  some  value  in  that  form  of  cardiac 
disease.  My  own  observations  have  not  been  numerous 
enough  to  enable  me  to  corroborate  this  statement. 

''  Dr.  Angus  Macdonald  has  recently  published  a  work  on 
the  'Bearings  of  Chronic  Disease  of  the  Heart  upon  Preg- 
nancy, Parturition,  and  Childbed,'  which  is  of  the  great- 
est interest;  but  unfortunately  he  does  not  discuss  the 
questions  of  whether  leucorrhoea  is  common  in  women 
with  heart-disease,  or  what  is  the  effect  upon  the  amount 
of  the  menstrual  flux.     So  far  as  my  impressions  go,  for 


122  SECONDARY  INDIGESTION.         [chap.  yi. 

I  have  no  exact  data  on  the  subject,  these  outcomes  of 
fulness  of  the  pelvic  veins  are  not  so  influenced  by  disease 
of  the  heart  as  might  d  priori  have  been  expected." 

When  this  condition  of  venous  fulness  is  the  cause  of 
indigestion,  it  is  obvious  that  the  therapeutic  measures 
must  be  directed  to  the  improvement  of  the  circulation. 
If  the  circulation  can  be  relieved,  the  uncomfortable  sen- 
sations will  pass  away  along  with  the  catarrh  with  which 
they  are  casually  related.  Astringents,  as  compound  kino 
powder,  are  very  efficacious  in  simple  primary  gastric 
catarrh;  but  in  those  cases  where  the  circulation  is  the 
cause  of  the  catarrh,  they  are  also  useful,  but  to  a  much 
less  extent.  It  is  better  practice  to  put  the  patient  in  bed, 
so  as  to  give  the  heart  as  little  work  as  possible  to  do;  to 
improve  its  condition  by  giving  agents  like  digitalis  and 
strychnia,  which  act  directly  upon  the  heart  and  increase 
the  vigour  of  its  contractions,  so  that  the  heart  fills  the 
arteries  by  emptying  the  veins — -rfor  that  is  really  the  func- 
tion of  this  "blood-pump;"  and  to  relieve  the  fulness  of 
the  venous  radicles  by  evacuants,  as  hydragogue  cathar- 
tics, and  diaphoresis  produced  by  the  application  of  heat. 
When  the  blood  is  relieved  of  a  quantity  of  water  by  these 
measures,  then  the  venous  fulness  is  relieved,  and  with  it 
the  catarrh  which  is  its  consequence.  Strict  dietary  is  in- 
dispensable to  the  relief  of  such  cases.  An  error  in  diet 
is  fraught  with  mischief  which  may  persist  for  long.  In- 
deed, the  correct  regulation  of  the  dietary  will  tax  the  re- 
sources of  the  physician  to  the  utmost.  But  the  results  to 
the  patient  are  very  grateful  and  agreeable,  as  well,  too,  as 
to  the  doctor's  self-pride. 


CHAP.  VI.]         SECONDARY  mBIGESTION.  123 

There  is  still  another  form  of  "  secondary  indigestion  " 
which  remains  to  be  described;  and  that  is,  the  **  toxsemic  " 
form. 

Mal-nutrition,  the  result  of  a  poison  in  the  blood,  is 
far  from  an  uncommon  occurrence.  The  presence  of  the 
poison  interferes  with  assimilation  generally,  and  the  for- 
mation of  the  complex  body — haemoglobin,  in  particular. 
Consequently  anosmia  is  a  common  feature  in  the  case 
of  mineral  poisons,  as  mercury  and  lead;  in  miasmatic 
poisons  like  that  of  malaria;  in  poisons  acquired  or  pro- 
duced, as  syphilis  and  gout.  These  two  latter  poisons 
commonly  interfere  largely  with  the  assimilative  organs 
and  their  functions.  As  gout  will  be  dealt  with  in  extenso 
in  the  second  part  of  this  work,  nothing  more  need  be  said 
about  its  effects  upon  nutrition  here.  But  it  is  necessary 
to  say  something  about  syphilis.  Young  persons  with  con- 
genital syphilis  often  present  conditions  of  mal-nutrition 
and  ansemia,  especially  the  latter,  where  the  ordinary 
measures,  including  the  administration  of  chalybeates,  are 
impotent  to  initiate  improvement;  but  where  the  addi- 
tion of  mercury  or  iodide  of  potassium  acts  like  a  charm. 
The  syphilitic  infant  is  a  sorry  spectacle.  Its  puny  limbs, 
the  skin  either  hanging  in  folds,  or  dry,  harsh,  and  dirty; 
its  wasted  muscles;  its  withered  face,  approaching  the 
wrinkled  face  of  age;  its  sore  eyes,  often  with  a  discharge; 
the  characteristic  "snuffles;  "  its  whining,  moaning,  feeble 
cry;  the  presence  of  a  coppery-tinted  blush  upon  its  nates 
and  around  its  anus,  sometimes  with  condylomata,  some- 
times with  a  general  rash  more  or  less  developed.  It 
is,  indeed,  an  object  in  more  senses  than  one.     It  is  piti- 


124  SECONDARY  INDIGESTION'.         [chap.  yi. 

able  for  its  own  sake,  from  pure  humanity;  it  is  pitiable 
morally  as  an  illustration  that  the  sins  of  the  father  are 
■undoubtedly  visited  upon  the  children;  it  is  pitiable  to  see 
the  fond  mother's  love  given  to  so  sorry  a  babe.  Ordinary 
measures  are  impotent  here  to  affect  any  good.  Mercury 
is  the  specific.  When  this  is  added  the  child  fattens,  its 
little  wasted  limbs  grow  plump;  the  rash  disappears;  the 
'^  snuffles  "  vanish;  the  eyes  recover  their  normal  aspect; 
it  is  the  difference  betwixt  a  changeling,  an  elfish  goblin, 
and  a  human  baby. 

But  it  is  not  in  children  only  that  such  ^'  toxfemic  "  mal- 
assimilation  is  found.  The  following  case  illustrates  this 
form  of  indigestion..  A  friend  of  mine  wrote  to  me  in  the 
spring  of  1880  a  most  dolorous  account  of  his  sufferings 
from  indigestion,  which  had  proved  most  intractable,  in- 
deed, had  deiied  all  the  resources  of  a  careful  painstaking 
provincial  physician.  I  wrote  to  him  sketching  out  a 
dietary  to  be  strictly  adhered  to  in  addition  to  the  medi- 
cinal treatment,  which  was  all  that  could  be  desired.  No 
improvement  took  place;  the  indigestion  being  as  unpleas- 
ant as  ever.  Late  in  the  autumn  he  presented  himself 
with  a  local  malady,  a  persistent  pain,  which  was  found 
to  be  due  to  a  periosteal  thickening,  nipping  a  sensory 
nerve.  I  found  out  a  history  of  syphilis  long  3'ears  ago, 
which  had  been  forerotten,  until  cross-examination  brousfht 
it  to  mind;  so  little  indication  of  its  presence  had  it  given. 
In  order  to  be  quite  sure  about  the  diagnosis,  on  which 
hung  both  the  prognosis  and  the  treatment,  I  took  him  to 
Jonathan  Hutchinson  for  his  opinion.  He  quite  coincided 
with  the  view  taken.     The  patient  was  put  upon  iodide  of 


CHAP.  ^^.]         SECONDARY  INDIGESTION.  125 

potassium  with  immediate  improvement  as  to  the  pain; 
not  only  that,  but  the  indigestion  has  disappeared.  I  had 
told  him  that  it  was  possible  it  might  be  found  to  do  so. 
That  the  underlying  factor  was  the  unrecognised  syphilis, 
in  all  probabilit}^,  and  that  the  specific  treatment  might 
cure  the  indigestion  as  well  as  the  pain.  He  improved 
much  after  this  treatment  was  adopted. 

Doubtless  there  are  many  such  cases  if  they  were  only 
recognised.  We  are  beginning  to  be  familiar  with  "  vis- 
ceral syphilis,"  in  the  form  of  structural  changes  set  up 
by  it  in  the  viscera;  but  as  a  cause  of  functional  de- 
rangement, its  influence  has  scarcely  yet  been  recognised. 
In  time,  probably,  this  will  generally  be  admitted. 

Such  then  are  some  of  the  relations  of  indigestion,  which 
are  not  described  in  our  ordinary  text-books;  but  of  which 
the  practitioner  must  know  something,  in  his  own  interests 
as  well  as  those  of  his  patients.  They  require  for  their 
recognition  that  careful  interpretation  of  subjective  phen- 
omena which  has  been  largely  lost  sight  of  in  recent  years, 
in  the  too  exclusive  devotion  to  the  signs  furnished  by 
physical  examination.  Indeed,  it  is  the  individual  which 
must  be  studied;  not  a  diseased  entity,  described  by  a 
word  or  a  phrase,  presenting  certain  objective  indications. 
Further,  the  successful  treatment  of  these  secondary  forms 
of  indiofestion,  involves  somethins-  more  and  outside  mere 
dietary,  however  indispensable;  and  the  administration  of 
the  usual  remedial  agents:  it  comprises  attention  to  the 
exciting  cause  and  measures  strictly  adapted  thereto. 
When  made  thus  comprehensive,  the  treatment  contains 
the  elements  of  success — at  least  potentially. 


CHAPTER  VII. 

INDIGESTION  AS  AN  INTERCURRENT  AFFECTION. 

This  is  a  very  important  matter  for  the  patient,  and  not 
insignificant  for  the  practitioner.  The  aspect  of  a  case 
may  suddenly  be  clouded,  like  a  bright  April  day  may 
suddenly  alter  with  the  swift  oncome  of  a  dark  rain- 
cloud,  racing  up  with  the  wind.  It  may  shew  at  first 
'^ike  a  man's  hand  "  arising  out  of  the  sea,  as  did  that 
which  caused  Elijah  to  send  word  to  Ahab,  yet  ''  it  came 
to  pass  in  the  meanwhile,  that  the  heaven  was  black  with 
clouds  and  wind,  and  there  was  a  great  rain."  So  the 
prospects  of  a  case  may  be  suddenly  obscured;  and  almost 
'before  danger  is  scented,  the  aspect  may  be  profoundly 
changed.  A  little  nausea,  the  surface  of  the  tongue  alter- 
ing, a  rise  of  temperature,  and  the  case  doing  well,  may 
be  suddenly  endangered  ;  as  the  Eurydice,  sailing  with 
her  stun-sails  set,  was  sunk  bodily  by  a  squall  coming 
up  unnoticed  behind  Shanklin  Downs. 

The  wary  and  experienced  practitioner  knows  the  im- 
port of  such  threatenings;  a  rise  in  the  temperature  is 
as  significant,  and  ominous  withal,  as  a  sudden  fall  of 
the  barometer  tells  of  comins:  storm.  Just  as  the  seaman 
furls  his  topsails,  and  puts  the  ship  under  bare  poles,  unless 
it  be  a  storm-jib,  when  the  barometer  suddenly  falls  for  a 
typhoon;  so  when  the  medical  man  sees  the  thermometer 
suddenly  rise,  he  is  on  the  alert  as  to  the  other  indicia  of 
coming  storm.     But  there  are  other  semeia  of  threatening 


CHAP,  vn.]  INDIGESTION.  127 

danger  even  earlier  than  this  palpable  change;  like  the 
stormy  petrel  that  precedes  the  gale,  the  tongue  grows 
irritable,  red,  angry-looking,  or  abnormally  bare  and 
smooth;  there  is  restlessness,  some  nausea,  the  appetite 
is  lost  or  very  capricious,  the  sleep  is  disturbed;  such 
are  the  symptoms  which  immediately  arrest  our  attention, 
or  ought  to  do  so.  The  rise  of  temperature  converts  sus- 
picion into  certainty;  but  usually  it- is  well  not  to  wait  for 
this  corroboration,  but  to  act  promptly  on  the  first  sus- 
picion. The  case  may  be  one  of  pneumonia,  it  may  be 
of  surgical  operation,  or  of  typhoid  fever.  No  matter 
what  the  form  of  disease,  when  these  indications  of  acute 
disturbance  in  the  digestive  tract  shew  themselves,  it  be- 
hooves the  practitioner  to  put  the  hands  on  deck;  the  craft 
is  in  danger,  more  or  less  imminent.  The  coming  risk 
must  be  faced.  To  use  another  simile,  when  a  general 
sees  that  he  is  beins:  threatened  with  a  flank  movement, 
he  makes  his  disposition  accordingly;  he  changes  his  front 
so  as  to  face  his  new^  foe. 

So  it  must  be  with  the  medical  practitioner.  He  must 
meet  the  new  danger;  and  many  a  patient  is  needlessly 
lost  for  want  of  this  rapid  change  of  front.  If  the  new 
intercurrent  attack  proceed  to  vomiting,  then  the  prospect 
becomes  vastly  grave,  indeed.  If  food  cannot  be  retained, 
the  patient  will  sink.  Nutritive  enemata  may  keep  the 
case  floating  a  while;  but  only  a  little  while,  not  for  long. 
In  many  cases,  the  change  is  due  to  pushing  alcoholic 
stimulants  too  freely;  in  others,  alcohol  is  urgently  called 
for.  All  depends  upon  the  precise  facts  of  each  case. 
The  medicines  previously  given  are  often  to  be  withheld; 


128  INDIGESTION,  [chap.  vn. 

however  strong  the  necessity  for  resort  to  them  may  seem. 
The  usual  mixture  of  bismuth  and  soda  in  calumba,  with 
a  drop  or  two  of  hydrocyanic  acid,  or  a  few  grains  of 
bromide  of  potassium,  alone  is  permissible.  The  bland- 
est of  food,  a  little  white-wine  whey,  or  milk  and  lime- 
water;  if  the  milk  is  at  all  likely  to  be  curdled,  a  few 
grains  of  prepared  chalk,  or  light  carbonate  of  magnesia, 
may  be  stirred  into  it,  or  a  little  baked  flour  to  lessen 
the  firmness  of  the  curd.  If  beef-tea  be  given,  let  it  con- 
tain some  baked  flour,  to  give  it  some  more  actual  food 
value,  compared  to  what  it  possesses  alone. 

Let  whatever  be  taken,  be  small  in  quantity  at  once: 
little  and  often  !  If  the  outlook  be  very  clouded,  it  may 
be  well  to  resort  to  the  partially  digested  milk,  or  milk- 
gruel  of  Dr.  Wm.  Roberts.  If  there  be  tympanitis,  a 
turpentine  stupes,  or  a  liniment  of  chloroform  on  a  few 
folds  of  lint,  covered  with  an  overlapping  piece  of  oil-silk 
are  good.  If  vomiting  actually  set  in,  give  a  hypodermic 
injection  of  morphia  at  once,  sufficient  to  "  quiet  "  the 
stomach.  If  there  co-exist  danger  of  paralysing  the  re- 
spiration or  the  heart  by  the  dose  of  morphia,  give  with  it 
a  little  sulphate  of  atropia  (morphia  gr.  |-,  liq.  atropia 
sulph.  gtt.  ii.) ;  this  obviates  any  danger  arising  from  the 
morphia.  Before  the  days  of  the  hypodermic  injection, 
opium  or  morphia  had  to  be  given  per  rectum.  In  a 
case  of  intense  vomiting  seen  when  a  youth,  I  remember 
my  father  giving  a  dram  of  laudanum  in  a  starch  enema, 
with  excellent  effects.  In  a  couple  of  hours  the  stomach 
tolerated  a  morphia  draught,  which  acted  topically  upon 
the  stomach  as  well  as  systemically;  after  the  crisis  was 


CHAP,  vn.]  I^^DIGESTION:  129 

passed,  the  management  of  the  case  was  comparatively 
simple.  Now  the  hypodermic  syringe  has  diminished  the 
difficulties  materially;  and  in  the  hands  of  a  man  at  once 
wary  and  courageous,  is  simply  invaluable  in  emergencies. 
Sometimes  when  the  symptoms  are  not  quite  so  threaten- 
ing, or  the  case  so  urgent,  it  is  sufficient  to  give  a  tiny 
mite  of  a  pill,  as  a  grain  of  the  extract,  opii  at  bedtime, 
or  to  add  to  it  gr.  \  of  morphia.  So  small  a  thing  does  not 
irritate  the  stomach  by  its  presence,  a  matter  of  the  very 
highest  importance.  If  there  be  great  thirst,  and  the 
patient  gulps  fluid  down  eagerly,  it  will  be  up  again  im- 
mediately; having  done  no  good,  and  only  furthered  the 
exhaustion:  let  a  chip  of  ice  slowly  dissolve  in  the  mouth 
and  cool  the  fauces,  the  local  seat  of  thirst.  A  little 
cream  ice  is  at  once  cooling  and  nutritive;  or  iced  milk 
may  slowly  be  sipped,  or  sucked  through  a  straw,  or  a 
glass  tube. 

But  a  little  at  once:  or  it  is  an  instance  of  "the  more 
haste,  the  less  speed."  Patience  and  watchfulness  must 
be  combined  with  promptness  of  action,  when  the  time 
for  action  arrives.  Judicious  nurses,  whose  muscles  of 
expression  are  under  complete  control,  so  as  not  to  betray 
their  inward  anxiet}'",  are  to  be  desired.  All  injudicious 
and  emotional  friends  are  to  be  banished,  energetically 
and  remorselessly;  it  is  no  time  for  folly,  no  matter  how 
near  the  tie,  how  close  the  relationship!  The  link  of  blood 
does  not  justify  culpable  homicide  in  the  interests  of  the 
individual  dangerously  ill.  A  darkened  room;  perfect 
quiet;  no  disturbing  element  must  be  allowed  to  enter 
by  eye  or  ear.     Brain  and  stomach  alike  must  have  ab- 


130  imyiGESTION.  [chap.  vn. 

solute  rest.  A  cool  clear-headed  pilot  at  the  helm,  and 
a  capable  crew  tendering  willing  obedience,  and  the  craft 
may  be  steered  through  the  peril  into  smooth  water.  A 
wrong  move  at  the  critical  moment,  and  all  is  swiftly  over; 
and  regret  is  unavailing.  To  meet  a  grave  emergency 
coming  on  swiftly,  taxes  all  the  resources,  all  the  capacity 
of  the  medical  attendant;  and  is  a  sharp  test  of  the  man 
as  well  as  the  practitioner.  Wealth  of  resource,  fertility 
of  thought,  the  moral  courage  to  accept  the  responsibility 
of  energetic  action;  all  are  required  in  these  times  of  ex- 
treme peril. 

When  the  stomach  is  irritable,  it  must  be  compromised 
with;  there  is  no  alternative.  So  long  as  it  is  patient 
and  tolerant,  medicine  to  affect  other  parts  may  be  given; 
but  when  the  stomach  itself  is  out  of  order,  its  moods  must 
be  met;  it  must  be  humoured  and  conciliated.  It  is  no 
good  to  attempt  to  master  it!  Just  as  Mahomet  had  to 
go  to  the  mountain  when  the  mountain  did  not  go  to  him; 
so  when  the  stomach  is  in  active  revolt  it  must  be  com- 
promised with,  and  soothed.  High-handed  measures  are 
out  of  the  question.  Conciliation  alone  is  feasible;  and 
it  must  be  practised.  The  stomach  is  the  suffering  slave 
of  humanity  ordinarily,  but  when  it  is  in  revolt  it  must  be 
compromised  with,  and  coaxed  into  submission.  Certainly 
the  hypodermic  syringe  has  worked  a  marvellous  improve- 
ment in  our  measures  of  dealing  with  the  stomach  in  emer- 
gencies; but  the  difficulties  are  quite  great  enough  which 
still  remain.    We  cannot  be  hio-h-handed  with  the  stomach! 

In  attacks  of  typhoid  fever,  when  the  tongue  goes  red 
and  irritable,  the  aspect  of  the  case  grows  dark  like  the 


CH.^.  vn.]  lyDIGESTIOy.  131 

niorHt-fall  "svith  rain  and  a  shrinkinor  barometer.  The 
dietary  of  the  patient  becomes  everything,  or  almost  every- 
thing; the  medicinal  part  of  the  treatment  being  modified 
at  the  same  time.  The  patient  may  have  been  under  no 
treatment,  or  merely  some  hydrochloric,  phosphoric,  or, 
still  better,  hydrobromic  acid  may  have  been  given  in 
syrup  and  water  every  few  hours  ;  but  when  the  tongue 
chang'es,  it  is  time  to  examine  the  stools  for  the  curd  of 
milk.  This  is  far  too  little  attended  to  by  the  practitioner, 
even  if  familiar  with  typhoid  cases.  At  the  Fever  Hospi- 
tal, Islington,  under  Drs.  Broadbent  and  Mahomet,  such 
watchful  inspection  is  constantly  practised.  AYhen  the 
undigested  curds  tell  that  the  assimilative  powers  are 
upset,  then  it  is  well  at  once  to  add  some  baked  flour 
to  the  milk,  or  to  mix  it  in  equal  quantities  with  lime- 
water  ;  or  to  give  instead  some  rice-water,  or  thin  arrow- 
root. The  Americans  are  fond  of  a  sliced  lemon  and  two 
ounces  of  sugar  being  placed  in  a  jug  and  a  quart  of 
boiling-water  poured  upon  them  ;  after  that  to  add  the 
white  of  an  egg,  and  froth  it  up.  Such  is  a  pleasant 
drink.  Always  be  it  remembered,  that  sugar  requires 
very  little  digestion,  it  soon  finds  its  way  into  the  blood, 
and  next  to  alcohol  is  the  easiest  digested  food  we  have. 
(This  matter  will  be  referred  to  again  in  the  ensuing 
chapter).  A  little  beef-tea  or  white  wine  whey  may  be 
desirable,  until  the  digestive  tract  is  once  more  fit  to  as- 
similate milk  :  and  then  it  is  well  to  besrin  ao-ain  with 
milk  in  small  quantities,  and  not  alone,  or  unmixed  with 
alkalies  or  diluents.  Such  must  be  the  method  of  proce- 
dure— or  disaster  will  not  be  far  ahead. 


132  indigestion:  [chap.  vn. 

Then  again  there  are  more  persisting'  disturbances  of 
digestion  which  manifest  themselves  in  the  course  of  more 
chronic  disorders.  There  is  a  weak  spot  in  the  organism, 
sa}^  a  consolidated  lung-apex,  quiescent,  doing  no  harm  : 
strictly  latent,  merely  impairing  a  little  the  thoracic 
capacity.  Such  a  state  is  a  very  common  occurrence. 
But  let  the  digestion  become  disturbed  and  with  it  the 
nutrition  :  and  what  then  ?  When  a  regiment  of  soldiers 
do  a  long  march,  who  falls  out  first  ?  Those  who  are  not 
strong;  those  who  have  been  enfeebled  and  thereby  un- 
fitted for  such  demand  upon  them  !  So  it  is  with  the  body; 
when  the  nutrition  is  impaired  it  is  the  "  weak  spot "  that 
feels  it  first,  and  most  intensely.  The  lung-apex  from  a 
static  condition,  free  from  danger,  commences  to  break 
down  ;  its  nutrition  is  lowered  beyond  the  point  when  it 
can  maintain  its  existence,  and  it  commences  to  die  piece- 
meal by  molecular  necrosis.  It  undergoes  fatty  histolysis, 
it  softens;  around  its  periphery  is  a  zone  of  ulceratioDj 
which  sets  up  hectic  fever;  and  in  its  death  it  may  involve 
the  fate  of  the  organism.  Comparatively  unimportant, 
its  existence  is  transformed  into  a  grave  matter  when  the 
tissue-nutrition  is  impaired  by  disturbance  in  the  assimila- 
tive processes. 

In  the  quiescent  static  condition  the  area  of  lung  which 
has  undergone  consolidation  is  a  matter  for  little  if  any 
anxiety,  further  than  as  a  potential  element  of  danger;  but 
when  breaking  down  it  is  transformed  into  a  very  grave 
matter  indeed,  the  danger  is  tangible  and  present  ;  the 
potential  has  been  realised. 

In  the   same  way  we   see  individuals  the   subject   of 


CH.^.  ^Ti.]  IXniGESTIOy.  133 


chronic  valvular  disease  of  the  heart.     A  certain  injury  of 
a  permanent  incurable  character  has  been  done  to  the  val- 
vular mechanism  ;  this  is  compensated  by  muscular  growth 
known  as  hypertrophy.     As   long    as    the   compensatory 
growth  is  maintained  the  case  goes  on  well.     If  the  valvu- 
litis is  of  the  progressive  order  then  the  muscular  compen- 
sation must  go    on  ^j>a;-i  lyassu,    else    the    compensating 
power  becomes  insufficient,  and  the  case  moves  on  down 
hill ;  as  too  many  do.     But  in  many  instances  the  injury 
to  the  valve  is  done  and  over  ;  it  is  like  a  mutilated  hand, 
which  is  not  what  it  was  in  its  pristine  integrity,  it  is 
crippled — but  there  is  no  tendency  in  the  mutilation  to 
proceed  further.     So  in  many  cases  of  valvular  disease  of 
the  heart,  the  mischief  is   done — the  mutilation,  such  as 
it  is,  is  worked  ;  but  the  condition  is  that  of  a  cicatrix  or 
scar,  it  is  static  and  has  no  tendency  to  progression.     In 
these  cases,  which  are  far  from  uncommon,  so  long  as  the 
muscular  hypertrophy  is  maintained  so  long  is  the  compen- 
sation perfect.     But  when  the  digestion  fails,  when  the 
nutritive  pabulum  to  this  hypertrophied  muscle  is  insuffi- 
cient,  the   prospect  changes.     From   a    static    condition, 
downward  progress    is   instituted  ;  which   if  not  quickly 
stayed,  will  bring  the  organism  to  wreck  and  ruin.     It  is 
like  progressing  over  a  level  plateau,  and  then  coming  to 
a  precipitous  declivity. 

Again  the  bright  sky  is  suddenly  clouded.  A  patient 
•with  aortic  regurgitation,  a  very  clever  artist,  knows  this  as 
well  as  I  do  ;  and  speaks  as  feelingly.  So  long  as  his 
nutrition  is  good,  he  is  unconscious  of  his  heart,  and  feels 
well  subjectively  :  but  when  indigestion  is  provoked  then 


134  INDIGESTION.  [chap.  vn. 

lie  becomes  acutely  conscious  of  his  heart,  and  of  its 
impaired  power.  He  realizes  that  if  his  digestion  was  to 
be  greatly  disturbed,  his  static  heart  condition  would  soon 
take  an  undesirable  movement  in  a  downward  direction. 

This  matter  of  possible  loss  of  assimilation  in  an  indivi- 
dual who  has  a  weak  spot,  whose  weakness  renders  perfect 
nutrition  a  necessity,  is  one  which  must  have  more  atten- 
tion given  to  it  in  the  future  than  it  has  had  in  the  past. 
A  consumptive  man  gets  engrossed  in  business,  for  which 
he  is  quite  fit  physically,  if  and  provided  he  takes  proper 
care  of  himself  ;  but  he  gets  carried  away  by  overwork, 
cannot  spare  a  sufficient  time  for  his  meals  ;  and  what  then 
ensues  ?     His  digestion  becomes  impaired,  and  the  blood  is 
insufficiently  fed.     The  tissues   are  ill-nourished   by  the 
poverty-stricken  blood.     The  healthy  tissues  get  on  fairly 
well  on  these  half-rations,  but  the  weakened  piece  of  lung 
breaks  down  ;  and  in  its  necrosis  all  but  carries  off  the  rest 
of    the    organism — indeed  the   individual   swims    for    his 
life  ;  and  survives  with  a  cavity  where  that  deteriorated 
piece  of  consolidated  lung  once  was.     It  has  been  a  very 
near  thing,  a  close  shave  !     Or  a  woman  has  a  static  mitral 
lesion,  which  has  lasted  for  years  without  progress  of  any 
kind.      She  marries,  becomes  pregnant,  has  a  difficult  par- 
turition, her  health  is  further  impaired  by  suckling  ;  this 
occurs  once  or  oftener.     The  muscular  hypertrophy  which 
compensates  the  lesion  begins  to  suffer  from  the  general 
mal-nutrition  ;  the  muscle  yields,  and  a  downward  course 
swift   and  certain,  is  set  up.     It  is  just  the  company  of 
soldiers  over  again  ;  under  a  severe  demand  the  weakest 
break  down  first.     Or  in  famine  the  liealthy  members  sur- 


CHAP,  vn.]  INDIGESTION.  135 

vive,  heaving  been  hardly  tested  ;  but  poor  Tom  !  whose 
lungs  were  bad  to  start  with  ;  he  succumbed.  A  tomb- 
stone tells  of  hiui  ! 

Unfortunately  in  the  body-family  one  member  cannot  die 
out,  and  leave  the  rest.  He  must  live  with  them  ;  or  they 
must  die  with  him  ! 

Hence  the  terrible  necessity  for  seeing  that  the  **  poor 
Tom  "  of  the  tissues  does  not  die,  when  the  evil  day  of 
famine  allowances  arrives.  Many  a  person  in  apparent 
health,  but  really  possessed  of  one  of  these  latent  sources 
of  danger,  is  laid  prostrate  by  severe  disease  as  tyjDhoid 
fever,  and  ague  ;  he  survives  the  storm,  but  a  weak  lung- 
apex  breaks  down  in  the  mal-nutrition  which  follows  in  its 
wake.  Or  he  undertakes  a  hard  life — goes  out  to  Manitoba, 
to  farm,  or  to  Colorado,  New  Mexico,  or  Texas,  as  a  cattle 
stockman,  turns  consumptive  and  just  lives  to  get  home  to 
die.  Or  he  manifests  some  luno-  mischief  and  is  sent  out 
to  Australia,  finds  it  suits  him,  and  settles  on  a  sheep-farm. 
The  fresh-air  and  outdoor  life  agree  with  him  :  and  for  a 
while  all  is  well.  But  the  food  taken  at  irreai-ular  intervals 
and  prepared  anyhow,  or  nohow  ;  the  resort  to  strong  tea 
as  an  invio^oratino:  beverasj'e  is  baneful  ;  after  a  while  the 
assimilation  becomes  decidedly  impaired,  the  blood  is  ill 
fed  ;  the  weak  bit  of  lunor  ig  starved  and  breaks  down. 
And  the  individual  goes  down  with  it  ;  or  survives  a  wreck, 
a  dismantled  hulk,  fit  for  no  more  active  service. 
.  It  is  this  relation  pf  the  ^^  weak  spot"  to  intercurrent 
indi2:estion  which  demands  such  careful  consideration  when 
determining  upon  a  rough  life  abroad. 


CHAPTER  VIII. 

DIET  AND  DRINK. 

These  two  practical  matters  require  a  few  words  to  them- 
selves. Of  course  what  is  written  here  only  admits  of  a 
general  application  to  cases  of  indigestion ;  each  case 
requires  to  have  the  treatment  fitted  to  it,  just  as  a  tailor 
fits  a  suit.  Nevertheless  some  generalizations  may  be  use- 
ful; chiefly  in  the  direction  of  what  is  to  be  avoided.  And 
first  and  foremost  comes  the  question  of  the  albumin- 
oids. Hydrocarbons  once  assimilated  give  no  trouble  in 
their  metabolism  within  the  body.  Certain  it  is  that  gly- 
cosuria may  be  a  disease,  and  a  very  serious  one  ;  but  it  is 
not  the  appearance  of  the  sugar  in  the  urine  which  is  the 
initial  disturbance,  it  is  the  outcome  thereof — the  out- 
ward visible  sign  of  inward  disorder.  It  is  not  the  origin 
of  the  thunder-cloud;  it  is  the  outcome  of  it,  the  thunder 
and  the  lightning.  Fat  may  be  deposited  until  it  becomes 
a  trouble,  to  say  the  least  of  it,  impeding  the  heart's  action 
when  accumulated  under  the  pericardium.  Sugar  and  fat 
lead  to  biliousness,  but  not  directly.  A  rich  meal,  in  good 
old  Saxon — a  "  surfeit,"  upsets  the  liver  ;  but  it  is  the  albu- 
minoids which  are  the  real  source  of  trouble.  The  hydro- 
carbons burn  up  readily  ;  to  invert  this,  we  may  say  that 
the  respired  oxygen  is  consumed  or  engaged  with  the  easily 
oxidisable  hydrocarbons ;  leaving  the  less  oxidisable  albu- 
minoids, which  unite  unwillingly  with  oxygen,  over,  i.e. 
little  affected,     These,  it  is  really,  which  are  the  source  of 


CHAP.  \iji.]  DIET  AND  DRINK.  137 

trouble.  It  is  these  albuminoid  elements  of  our  food  which 
cause  the  disturbance  after  a  "surfeit."  It  is  the  "luxus 
consumption"  of  albuminoids  which  is  the  initial  cause  of 
disturbance,  whether  in  "  biliousness  "  or  in  "  gout."  As 
to  the  latter,  this  is  srenerallv  admitted.  It  is  the  excess 
of  albuminoid  material  beyond  our  tissue-requirements, 
which  we  eat  that  is  the  source  of  all  our  woes.  In  the 
present  meat-eating  wave  of  fashion  this  excess  or  '■'  luxus 
consumption,"  is  the  cause  of  many  maladies.  We  over- 
load the  assimilative  processes  and  they  break  down  under 
the  strain.  None  of  the  meal  is  properly  digested  ;  but 
there  is  the  waste  to  be  got  rid  off.  The  excretory  emunc- 
tories  are  taxed  to  eliminate  the  excessive  amount  of  waste 
matter,  and  various  maladies  spring  therefrom.  To  eat 
food  and  to  dio-est  it,  are  not  one  and  the  same  thino-. 
Bulimia  leads  to  mal-nutrition.  The  old  expression,  "the 
wolf  at  the  stomach,"  was  applied  to  cases  where  voracity 
was  associated  with  leanness.  The  ill-fed  blood  causes  the 
sensation  of  hunger  to  be  felt  acutely;  and  then  the  vora- 
city induced  by  the  bulimia  is  great,  but  unsatisfying. 
This  is  often  well  seen  after  measles  in  children,  they  are 
hungry  all  day  long.  They  eat  and  eat  unceasingly  to 
appease  the  pangs  of  hunger;  but  in  vain.  The  more  they 
eat  the  worse  they  thrive,  because  they  digest  little  or 
none:  and  unless  they  are  restricted  to  proper  meals  they 
virtually  eat  themselves  to  death.  The}"  die  of  hunger — 
of  actual  starvation — in  the  midst  of  unlimited  food,  and 
everlasting  eating.  To  eat  and  to  digest  are  not,  then, 
one  and  the  same  thiner. 

Let  me  here  quote  a  sentence  from  Dr.  Lauder  Brunton. 


138  DIET  AND  DRINK.  [chap,  xui. 

He  describes  the  man  who  is  "run  down"  and  needs  a 
holiday.  "Not  only  does  the  brain  seem  exhausted,  but 
the  whole  system  appears  to  be  languid  and  weak;  instead 
of  the  man  being  able  for  a  twenty  or  thirty  miles  walk, 
one  or  two  miles  produce  fatigue,  and  sometimes  an  in- 
tense languor  is  felt  without  any  exertion  at  all.  And  yet 
all  this  time  he  may  have  been  trying  to  keep  up  his 
strength.  He  takes  butcher's  meat  three  times  a  day,  per- 
haps also  strong  soups,  to  say  nothing  of  wine,  or  brandy 
and  soda  to  pick  him  up.  His  tissues  ought  to  be  getting 
sufficient  nourishment  to  enable  them  to  do  their  work, 
and  yet  it  is  evident  that  they  are  not  in  a  condition  to  do 
so.  The  man,  and  very  likely  his  friends  also,  wonder  at 
his  condition,  and  when  he  goes  to  his  medical  attendant 
to  describe  his  case  he  says — '  I  take  all  sorts  of  strength- 
ening things,  and  yet  I  feel  so  weak.'  If  instead  of  using 
these  words,  he  were  to  say,  '  Because  I  take  all  sorts  of 
strengthening  things  I  feel  so  weak; '  he  would  express  a 
part,  at  least,  of  the  truth."  Dr.  Brunton  holds  that  the 
mal-products  of  digestion  are  positive  depressent  poisons. 
The  subject  will  be  referred  to  again  more  at  length  fur- 
ther on.  Enough  here  to  shew  that  "  strong  food  does  not 
necessarily  involve  strength; "  rather  the  opposite  when 
the  digestion  is  impaired.  A  little,  well  digested,  feeds 
the  blood,  and  from  it  again,  the  tissues,  better  than  a 
large  meal,  none  of  which,  or  very  little  indeed,  is  prop- 
erly digested. 

Strong-  beef-tea,  made  from  almost  fabulous  amounts  of 
beef,  on  which  the  housewife  proudly  dilates — well,  it  is 
the  fashion,  so  it  must  be  spoken  of  with  circumspection — 


CHAP,  vm.]  DIET  Am)  JDRIXK  139 

is  a  fraud  I  or  something  akin  thereto.  Its  food  value  has 
yet  to  be  demonstrated  !  Not  long  ago  calves-foot  jelly  was 
indispensable  in  conditions  of  debility;  its  day  is  now  over, 
it  is  little  heard  of.  Strong  beef-tea,  meat  essences,  meat 
juice,  are  pleasant;  and  certainly  patients  think  they  are 
proper  things  for  the  debilitated.  Well  they  may  be  so;  if 
and  provided  they  take  something  else  as  well.  But  to 
give  the  starving  patient,  starving  in  the  midst  of  plenty, 
these  things  to  feed  him,  is  giving  him  a  stone  when  he 
asks  for  bread.  A  little  lio-ht  food  which  can  be  digested 
is  infinitely  better  for  him. 

This  is  something  like  what  should  be  arrived  at. 

Breakfast;  porridge,  oatmeal  or  hominy,  with  milk,  to 
start  with;  to  set  the  children  a  good  example  !  Then  a 
little  cold  meat,  or  bacon,  or  fish;  with  a  cup  of  coffee,  tea, 
or  cocoa.      Some  fruit. 

Lunch;  some  potatoes  mashed  with  plenty  of  milk  and 
butter,  better  still  cream,  peppered  and  salted,  and  browned 
before  the  fire.  A  little  cold  minced  meat  in  a  thin  layer, 
not  to  be  further  cooked  but  only  to  be  made  hot,  may  be 
added.  Some  cold  milk  pudding,  left  over  from  the  dinner 
of  the  day  before,  and  some  stev/ed  fruit.  A  glass  0"f  milk, 
a  glass  of  carlowitz,  claret,  or  sherry,  may  be  permissible; 
with  others  only  a  little  brandy,  or  whisky  and  water  agrees. 
Let  it  be  little. 

No  glasses  of  wine  betwixt  meals  to  "  whip  one  up." 
Such  habit  is  bad,  very  bad  ! 

Dinner;  a  little  light  soup,  some  boiled  fish,  very  little 
joint,  or  some  game,  or  entree  like  sweetbread,  or  spinach 
and  a  poached  egg',  some  milk  pudding,  and  stewed  fruit. 


140  DIET  AND  DRINK.  [chap.  vm. 

Wine,  two  glasses  of  the  \vines  mentioned,  or  a  glass  of 
Bucellas;  or  perhaps,  if  the  patient  be  very  sure  that  it 
does  good,  arid  suits  better  than  anything  else — one  glass 
of  port  wine;  or  a  little  spirits  and  water.  Aerated  waters 
are  objectionable,  they  are  too  gaseous;  while  alkaline 
waters  are  not  good  at  meal  times,  they  reduce  the  acidity 
of  the  stomach,  which  is  essential  to  the  disfestive  action  in 
the  said  stomach. 

Xow  as  to  dessert.  Perhaps  I  am  going  to  be  heretical; 
perhaps  only  "  a  little  advanced,"  Isuts  are  certainl}^  not 
to  be  advocated  for  the  dyspeptic.  Oranges,  pomeloes  and 
shaddocks,  are  like  grapes,  unobjectionable  if  the  juico 
only  be  swallowed;  apples,  pears,  plums,  gooseberries}, 
cherries,  strawberries,  each  and  all  are  good.  The  salts, 
potash  and  others,  of  sub-acid  fruits  are  good  for  "  the 
blood."  Often  these  fruits  are  forbidden  unnecessarily. 
If  they  disagree  let  them  be  avoided;  experience  must  be 
the  sole  judge  of  their  admissibility.  Only  they  need  not 
be  eschewed  wholesale,  as  is  too  much  the  rule. 

Bananas,  figs,  pine-apples,  raisins  (Sir  W.  Gull,  Bart., 
stated  his  partiality  for  raisins  before  a  Royal  Commission, 
therefore  there  can  be  no  doubt  about  their  value),  pre- 
served peaches  and  apricots,  when  the  fresh  fruit  cannot 
be  obtained,  are  also  good;  candied  fruits  perhaps  are  not 
as  a  rule  admissible.  We  eat  far  too  little  fruit  in  Great 
Britain  to  our  meals. 

Supper;  a  draught  of  milk  and  an  arrowroot  biscuit  is 
the  best  and  lightest.  It  is  rarely  required  except  after  an 
early  dinner.  Some  persons,  however,  must  take  their  food 
at  short  intervals,  because  they  can  only  digest  little  at  once. 


CHAP,  vm.]  DIET  AND  DRimC  141 

When  the  fast  betwixt  supper  and  breakfast  is  too  long, 
a  little  milk  and  a  biscuit  in  the  small  hours  of  the  morn- 
ing maybe  taken;  or  a  tumbler  of  milk  with  a  teaspoonful 
of  rum,  or  brandy  in  it  may  be  taken  on  getting  out  of  bed 
to  dress.  With  some  persons  this  enables  them  to  take  a 
fair  breakfast. 

Some  persons  can  eat  no  breakfast.  Not  uncommonly 
"they  eat  their  breakfast  before  they  go  to  bed;"  they 
make  a  good  supper;  this  is  very  common  with  business 
people  who  work  hard  all  the  day,  and  have  no  rest  till 
supper  time.  The  mistress  of  a  business  requiring  much 
jDersonal  attention,  is  apt  to  do  this.  She  commonly  be- 
comes a  dyspeptic;  if  her  digestion  can  stand  this  outrage, 
usually  she  ultimately  becomes  the  subject  of  gout,  in 
someone  or  other  of  its  many  forms. 

Some  dyspeptics  find  that  they  must  take  no  fluids  with 
their  food,  and  have  to  live  on  a  very  dry  dietary,  an  Arab 
dietary.  Others  require  more  fluids  than  they  allow  them- 
selves. 

Others  require  a  biscuit,  or  some  light  article  of  food 
"  betwixt  meals."  When  this  is  made  an  excuse  for  a 
glass  of  sherry,  it  is  to  be  closely  criticised  as  a  question- 
able habit,  "  more  honoured  in  the  breach  than  the  obser- 
vance." To  take  some  fruit  would  be  better  in  every  way. 
Some  succulent  fruit  would  satisfy  the  craving  '^  for  some- 
thing," and  would  not  require  the  beverage  "  to  get  it 
down."  Such  use  of  fruit  ought  to  be  more  general  than 
it  is  at  present.  In  all  households  where  the  expense-does 
not  forbid  it,  a  large  dish  of  picked  fruit  of  various  kinds, 
when  the  season  permits  of   it,  should  be  placed  on  the 


142  DIET  AND  BRINK.  [chap.  vni. 

side-board  every  morning,  with  a  label  "  Help  yourself  "  on 
it  (as  is  found  in  the  waiting  rooms  of  several  London 
consultants).  Children  would  soon  cease  to  overeat  them- 
selves, just  as  do  the  assistants  in  confectioners'  shops, 
when  they  realise  that  it  is  to  be  a  constant  affair,  not  an 
occasional  treat  to  be  made  the  most  of.  Such  an  idea  is 
well  worthy  of  adoption.  If  the  "  temperance  "  section  of 
society  would  set  the  example,  it  would  soon  be  followed  by 
others;  to  the  benefit  of  the  digestive  organs  of  many: 
while  it  would  be  agreeable  to  all.  Fresh  gathered  fruit 
out  of  the  garden  and  orchard  ought  to  be  placed  on  the 
breakfast  table  every  morning.  For  those  who  experience 
a  bitter  or  hot  taste  in  the  morning  on  awakening,  such 
addition  to  the  breakfast  table  would  be  most  acceptable. 
And  now  a  few  words  as  to  the  beverages  to  be  taken, 
Americans  are  a  dyspeptic  people;  they  drink  much  iced 
Avater  at  meals,  ergo,  iced  drinks  at  meal-times  are  bad  ! 
They  may  be,  when  carried  to  excess;  this  is  not  denied. 
But  iced  drinks  are  not  the  cause  of  the  widespread  dys- 
pepsia in  the  U.  S.  A.  There  are  other  potent  factors  in 
action.  Iced  drinks  are  very  grateful  to  the  thirsty,  but 
too  much  indulgence  therein  produces  a  torturing  thirst; 
as  the  person  who  indulges  in  eating  snow  in  the  Arctic 
regions  discovers  quickl}^  Just  as  snowballing  causes 
the  hands,  first  to  feel  cold,  and  then  to  glow  with  heat 
if  continued;  so  the  constant  application  of  an  iced  fluid 
to  the  fauces,  at  first  grateful,  becomes  a  source  of  intense 
discomfort  :  for  the  blood-vessels  are  first  contracted  and 
ultimately  paralysed,  and  then  the  fauces  glow  with  warm 
blood,  like  the  skin  of  the  snowballer's  hands. 


CHAT,  vm.]  DIET  AND  DRimC  143 

Iced  fluids  are  not  desirable  for  dyspeptics,  to  say  the 
least  of  it.  Ordinarily  at  dinner,  the  ice-pudding  is  fol- 
lowed by  a  glass  of  liquor — "  to  correct  it."  A  certain 
temperature  is  requisite  for  digestion,  and  too  much  cold 
is  undesirable. 

So  too,  the  stomach  is  acid  after  a  meal,  for  the  gastric 
digestion  is  acid;  therefore  alkaline  waters  are  contra-in- 
dicated at  meal-times.  They  should  be  taken  before  meals, 
properly,  when  the  stomach  is  alkaline.  The  milder  effer- 
vescing waters  are  comparatively  unobjectionable. 

Then  as  to  the  medicated  "temperance"  drinks.  The 
'zones  and  'dones  !  They  mostly  contain  phosphorus  and 
iron,  and  other  medicinal  matters;  and  therefore,  may  not  be 
taken  indiscriminately,  or  with  impunity.  For  well-nour, 
ished  persons,  and  still  more,  stout,  florid,  plethoric  individ- 
uals, they  are  unsuited.  For  the  pallid,  "  limp,"  listless  be 
ings,  they  are  well  adapted.  But  too  much  fluid,  even  a 
"  beverage  free  from  alcohol,"  is  not  without  its  drawbacks. 

As  to  alcoholic  beverages,  they  are  good  or  harmful  ac- 
cording to  the  use  made  of  them.  As  to  the  mischievous- 
ness  of  alcoholic  indulgence,  all,  "  the  total  abstainer,"  and 
his  less  rigid  brothers  and  sisters,  are  agreed.  Ifc  is  bad 
physically,  intellectually,  and  morally  !  But  what  would 
be  decided  excess  in  one  person  is  not  "excess"  in  an- 
other. Also  this  varies  in  the  individual.  There  are  times 
of  debility  when  generous  wine  may  be  freely  drunk,  not 
only  without  injury  but  with  benefit:  but  the  desire  for 
them  passes  away  as  the  indications  for  them  disappear. 
(It  is  not  forgotten  that  careless  medical  instructions  to 
drink  wine  freely,  have  led  to  sorrowful  results;  nor  that 


144  DIET  AND  BRINK.  [chap.  vm. 

a  patient  may  interpret  medical  instructions  liberall}'',  so 
as  to  make  an  excuse  for  alcoholic  indulgence.)  So  long 
as  alcoholic  drinks  improve  the  appetite,  do  not  heat  the 
patient,  and  do  not  disturb  the  tongue,  it  is  impossible  to 
say  they  are  doing  harm;  and  it  is  certain  they  are  doing 
good  and  agreeing.  The  physician  must  speak  out  with  a 
distinct  utterance,  ^^e.,  if  his  ideas  are  well-defined  and 
chiselled-out.  He  must  neither  pander  to  a  popular  taste 
for  alcoholic  beverages;  nor  be  afraid  of  the  strictures  of 
"  The  Temperance  Record,"  or  "  The  Alliance  News; " 
and  my  friends,  the  editors  of  these  two  earnest  publica- 
tions, must  excuse  me,  if  I  thus  take  up  a  position  dis- 
tasteful to  them.  They  must  allow  for  others  what  they 
claim  for  themselves, — i.e.,  "  the  courage  of  their  convic- 
tions." There  is  a  certain  unstable  temperament  in  cer- 
tain persons,  perhaps  a  part  of  the  neurosal  tendency  of 
the  age  which  must  be  taken  into  consideration.  Alike  in 
rural  Devonshire,  in  the  manufacturing  districts  of  Lan- 
cashire and  Yorkshire,  the  magistrates  are  aghast  at  the 
amount  of  Asylum  accommodation  they  are  called  upon 
nowadays  to  provide;  so  great  is  the  spread  of  lunacy. 
All  nervous  affections  are  on  the  increase.  Consequently 
there  is  a  growing  class  for  which  it  is  more  or  less  unde- 
sirable to  advise  stimulants,  especially  alcohol.  We  can- 
not now  order  a  glass  or  two  of  wine  daily  with  the  care- 
lessness of  yore.  It  is  growing  yearly  more  and  more 
unsafe  to  do  so.  Each  case  must  be  the  subject  of  con- 
scientious thought-  in  this  matter.  It  is  this  "  unstable 
temperament,"  against  which  the  medical  man  must  be  on 
his  guard  when  recommending  alcoholic  beverages. 


CHAP,  vm.]  DIET  Am)  DRIXK,  145 

Remembering  then  that  he  is  using  an  ''  edged  tool " 
that  ma}'  cut  both  ways,  and  in  full  consciousness  of  what 
he  is  doing,  tlic  medical  man  may  order  alcoholic  bever- 
ages. And  now  I  will  saj^  what  I  personally  think — 
dogmatism  would  be  improper. 

The  use  of  a  light  wine  is  not  undesirable  with  many 
persons,  from  Timothy  downward.  "  Wine  which  makelh 
glad  the  heart  of  man,"  sang  the  Psalmist,  in  a  hymn  of 
praise  and  thankfulness;  and  it  is  the  use  of  wine,  not  the 
abuse  of  it,  which  is  being  considered  here.  The  emo- 
tional temperament  mav.be  drunk  with  other  excitement 
than  that  set  up  by  alcohol.  "  They  are  drunken  but  not 
with  wine;  thev  staofo-er  but  not  with  stronsr  drink."  Ex- 
cess,  or  indulgence  in  wine  is  bad,  as  is  excess  in  anything 
else — medicated  non-alcoholic  beverages  not  excepted ! 
But  it  should  be  drunk  with  meals;  "  to  eat,"  as  they  say 
in  France  and  elsewhere. 

A  little  light  white  or  red  French  wine  is  admissible; 
Hock  is  more  apt  to  be  a  manufactured  wine.  Hungarian 
wine,  white  or  "  Carlowitz,"  and  Australian  wines  are  mak- 
ing good  their  claim  to  the  confidence  of  the  public;  some 
Italian  wines  are  very  palatable;  Greek  wines  also,  for 
those  who  do  not  dislike  the  flavor  of  resin  in  them.  The 
wines  of  Spain  and  Portugal  are  too  potent  for  ordinary 
use,  still  a  glass  of  sound  sherry  or  port  is  often  very  good; 
albeit,  more  money,  that  can  ill  be  spared,  is  thrown  away 
upon  port  wine  than  is  pleasant  to  think  of.  A  glass  of 
good  ripe  port,  or  of  Bucellas,  in  season,  and  in  the  right 
time,  toward  the  close  of  a  meal,  is  not  to  be  branded  as 
a  malefactor,  and  banished  from  society.  Marsala  is  usu- 
7 


146  DIET  AND  DRINK.  [chap.  vm. 

ally  a  trustworthy  wine,  and  its  bitter  flavor  is  in  its  favor 
as  a  wine  for  invalids. 

With  others  again,  a  little  plain  spirit,  brandy  or  whisky 
— Scotch,  Irish,  or  Bourbon,  even  "old  rye,"  not  absolutely 
forbidden,  is  their  best  beverage,  diluted  with  some  water. 

With  others  plain  water — "  Adam's  ale  " — is  the  best 
beverage. 

Malt  liquors  are  scarcely  suited  to  the  dyspeptic;  and  a 
little  sound  bitter  ale  alone  of  the  series  may  be  permitted 
to  the  sufferer  from  indigestion. 

But  for  the  dyspeptic  no  rule  "  absolute  "  can  bo  laid 
down  in  beverages  any  more  than  in  food.  Each  case 
requires  its  own  regimen  all  through.  Man}^  cases  of 
dyspepsia,  especially  when  there  is  moaning  sickness,  some 
catarrh,  excessive  flatulence,  a  foul  tongue,  and  an  un- 
steady eye,  are  due  to  alcohol  wholly  and  solely;  and  no 
reliance,  whatever,  can  be  placed  on  the  word,  statement, 
affirmation,  or  assertion  corroborated  by  solemn  oaths,  of 
a  drunkard;  for  "a  drunkard  is  a  liar  !  "  And  this  holds 
good  of  both  sexes,  and  all  ages;   everywhere  and  ever. 

Moderation  in  food,  especially  albuminoids  a  little,  prop- 
erly digested,  is  more  nutritive  than  a  feast,  none  of  which 
is  properly  or  completely  digested. 

Moderation  in  drinks,  especially  alcoholic;  the  via  media^ 
neither  total  abstinence  nor  excess. 

These  are  two  grand  rules  to  be  observed. 

Whey,  when  it  can  be  procured  fresh,  or  skimmed  milk, 
is  a  splendid  beverage  for  dyspeptics.  There  is  a  quantity 
of  nutritive  sugar  of  milk  in  it,  while  it  contains  all  the 
salts  of  milk. 


CHAP,  vm.]  DIET  AND  DRINK.  147 


This  leads  up  to  a  matter  not  altogether  unimportant, 
yet  rarely  remembered;  it  is  this, — sugar  is  a  very  easily 
digested  hydrocarbon.  Though  it  disagrees  with  many, 
with  most  dyspeptics  it  can  be  taken  in  greater  or  less 
quantity,  in  their  tea  or  coffee;  or  with  their  spirit  and 
water.  When  the  appetite  is  very  defective,  if  the  alcohol 
be  given  with  hot  water  and  sugar,  its  food-value  is  greatly 
enhanced.  Unfortunately,  it  cannot  always  be  so  taken; 
and  alone  with  cold  water,  plain  or  aerated,  must  it  be 
drunk. 

Finally,  tea  and  coffee  are  more  or  less  objectionable  and 
disturbing  to  dyspeptics.  Cocoa,  not  too  full  of  fat,  but 
thin,  is  better:  or  a  glass  of  milk:  or  the  tumblerful  of 
syrup  of  the  continent,  for  breakfast.  The  cup  of  tea 
before  getting  up  is  utterly  uncalled  for,  and  unmitigatedly 
bad.  Kettledrum  is  as  well  let  alone;  while  the  cup  of 
strong  tea  or  coffee  after  dinner  should  be  avoided  scru- 
pulously. 

The  incubus  of  fashion  and  conventionality  is  a  heavy 
burden  for  most  dyspeptics.  They  should  not  even  bathe 
before  breakfast,  if  they  have  sufi5cient  strength  of  mind 
to  brave  the  strictures  of  Mrs.  Grundy.  If  they  have 
not,  I  am  sorry  for  them;  nor  do  I  think  the  position  of 
their  medical  adviser  one  to  be  coveted.  Neither  the 
doctor  nor  the  patient  has  then  a  fair  field,  if  there  be 
lack  of  courage  moral,  or  other,  on  either  side! 


CHAPTER  IX. 

THE  FUNCTIONS  OF  THE  LIVER. 

The  liver  is  the  largest  gland  in  the  body;  indeed,  is  facile 
pririceps  among  these  organs,  both  as  regards  its  size  and 
the  importance  of  its  function.  To  many  readers  then, 
especially  the  junior  members  of  the  profession  and  stu- 
dents, to  whom  the  works  of  M.  Foster  and  other  physiol- 
ogists are  familiar,  it  will  seem  strange,  that  up  to  a  recent 
period,  the  liver  was  spoken  of  as  a  mysterious  terra  incog- 
nita, a  sort  of  Central  Africa  in  the  map  of  the  organism. 
Much  had  been  learned  empirically  as  to  disorders  and 
disturbances  of  health  referred,  not  inaccurately,  to  the 
liver;  and  their  appropriate  treatment  had  been  deter- 
mined with  much  clinical  acumen;  still  it  was  an  em- 
piricism unilluminated  by  scientific  knowledge. 

The  shrewd  practitioner  shook  his  head  sagaciously  in 
certain  cases,  and  oracularly  pronounced  the  word  "liver;  " 
ordered  slops  and  a  light  diet;  the  patient  followed  his  in- 
structions, and  felt  the  better  for  the  treatment.  The  bulk 
,of  empirical  testimony,  so  accumulated,  was  such  as  to 
carry  with  it  conviction  in  most  minds;  to  entitle  it  to 
respect  from  all  !  But  the  wave  of  disbelief,  which  is  now 
beginning  to  break,  swept  many  minds  away  with  it;  and 
because  infant  physiology  could  not  speak  articulately  as 
to  the  function  of  the  liver,  and  could  only  lisp  out  a  few 
limping  utterances,  the  store  of  empirical  lore  had  to  be 
thrown  aside  as  lumber, — without  value  or  claim  to  any 


CHAP.  IX.]        FUNCTIONS  OF  THE  LIVER.  149 


consideration.  To  such  a  humiliating  end  then  the  ob- 
servations of  centuries  had  to  be  relegated,  accordinir  to 
a  scepticism  as  conceited  as  it  was  unwarranted.  A  few  of 
the  harder-hearted  practitioners  clung  tenaciously  to  what 
experience  had  taught  them  ;  and  are  now  rewarded  for 
their  constancy,  by  seeing  modern  physiology  testifying 
to  the  accuracy  of  the  lessons  of  this  experience  of  their 
own,  and  of  observant  predecessors.  When  the  old 
practitioner  classed  "liver  and  kidney"  together,  when 
speaking  of  maladies  where  the  urine  was  altered  in  its 
appearance  and  reaction,  he  spoke  from  an  experience 
which  dated  back  as  far  as  Galen,  at  the  least.  That 
historic  phj^sician  knew  that  the  urine  solids  came  from 
the  liver;  how  he  knew,  how  he  or  some  one  else  arrived 
at  such  a  conclusion  with  the  means  they  then  possessed; 
it  is  simply  impossible  to  say.  They  were  keen  observers 
these  old  physicians,  and  could  sum  up  the  evidence  be- 
fore them  with  minds  eminently  judicial.  When  scientific 
knowledge  did  not  exist  in  any  form,  such  observations 
were  all  that  medicine  had  to  rely  upon. 

When  chemistry  began  to  break  a  path  for  a  truly  scien- 
tific knowledge  of  the  physiology  of  the  body,  the  matters 
easiest  to  examine  were  taken  first.  The  urine  naturally 
tempted  the  curiosity  of  chemists,  and  the  presence  of 
nitrogen  in  the  urine  solids,  disclosed  their  descent  from 
the  albuminoids  of  our  food.  The  kidneys  were  exalted 
to  honour.  In  old-standing  gout,  the  kidneys  were  found 
to  be  extensively  diseased.  The  imagination  then  bounded 
to  the  conclusion  that  the  kidneys  formed  uric  acid  and 
urea,  from  pre-existing  products  of  retrograde  nitrogenised 


150  FUNCTION'S  OF  THE  LIVER.        [chap.  ix. 

metamorphosis  in  tlie  blood.  I  can  well  remember  when 
the  statement  that  urea  was  formed  in  and  by  the  liver, 
and  only  excreted  by  the  kidneys,  was  received  as  the 
latest  utterance  of  a  school  not  entitled  to  the  confidence 
of  the  student-mind.  The  promulgators  of  that  view  were 
regarded  by  the  steady  old-fashioned  teachers,  much  as 
Melancthon  and  Luther  were  regarded  by  the  court  of 
Rome,  viz.,  as  unsound  heretics.  "  There  is  no  pain  like 
the  pain  of  a  new  idea,"  said  the  late  Mr.  Bagehot;  and 
to  many  minds  a  new  idea  unsettling  the  old-established 
notions,  is  excessively  painful.  Unless,  at  the  same  time 
that  it  brings  down  the  old  edifice,  it  is  prepared  with  a 
new  erection  to  take  its  place,  they  will  have  none  of  it. 
They  wilfully  shut  themselves  up  in  a  shell,  and  having 
once  assumed  this  attitude,  nothing  can  coax  them  out  of 
it.  The  storms  of  controversy,  the  intense  interest  in  the 
agonosphere,  affect  them  not.  In  the  language  of  the  late 
Lord  Beaconsfield,  once  applied  to  a  political  opponent 
about  a  measure  he  disapproved,  they  "  passionately  em- 
braced a  corpse."  They  hugged  their  defunct  impression 
till  the  odour  of  putrescence  compelled  them  to  cast  it 
away.  Such  is  the  present  position  of  the  generation  of 
medical  men,  who  are  beginning  to  pass  from  us. 

The  Croonian  Lectures  of  that  accomplished  physician 
the  late  Charles  Murchison,  delivered  before  the  Royal  Col- 
lege of  Physicians  in  1874,  took  the  medical  world  by  sur- 
prise. By  those  prepared  for,  and  seeking  a  new  faith,  they 
were  hailed  with  the  utmost  delight,  as  bringing  within  their 
reach  the  scientific  knowledge  they  thirsted  for;  to  such 
they  were  as  welcome  as  a  well  to  the  traveller  in  the  desert. 


CHAP.  IX.]        FUNCTIONS  OF  THE  LIVER.  151 

In  the  present  and  following  chapters  I  shall  avail  my- 
self as  largel}''  of  the  work  of  Murchison,  as  I  did  of  that  of 
W.  Roberts,  in  the  preceding  section  of  the  work  ;  and  ac- 
cordingly do  now  make  full  acknowledgment  of  my  in- 
debtedness to  Dr.  Murchison  for  all  that  he  told  us  in  these 
said  lectures  on  "  The  Functional  Derangements  of  the 
Liver."  Not  that  Dr.  Murchison  did  not  owe  much  to 
others,  as  he  himself  readily  and  generously  acknowledged; 
but  the  array  and  order  into  which  he  cast  a  huge  series  of 
isolated  facts  and  observations,  entitle  him  to  be  regarded 
as  the  preacher  of  the  new  faith  to  the  medical  profession 
in  England. 

Of  course  there  w^ere  many  others  working  in  the  same 
direction  as  Dr.  Murchison,  if  less  ably  and  less  enthusias- 
tically, and  to  whom  his  work  came  as  a  perfect  boon. 
Slowly  something  was  being  learned  about  the  liver. 
Chemistry  told  us  that  the  great  condiment  of  our  food, 
chloride  of  sodium,  was  split  up  in  the  body  into  hydro- 
chloric acid  for  the  gastric  juice,  and  soda  for  the  bile. 
The  utility  of  common  salt  in  the  organism  and  the  uni- 
versal craving  for  it,  were  alike  demonstrated.  The  long 
travel  alike  of  African  tribes  and  American  buffaloes  for 
salt  "licks,"  became  intelligible;  and  the  wickedness  of 
the  salt  tax  in  India  dawned  upon  the  mind.  The  liver 
secreted  bile;  that  much  was  certain;  and  bile  was  not 
merely  an  excrementitious  matter,  but  fulfilled  a  useful 
purpose.  The  liver  then  had  a  raison  d'etre  in  scientific 
medicine.  Perhaps  to  give  the  views  of  the  late  Dr. 
Kirkes  as  expressed  in  his  well-known  "  Handbook  of 
Physiology"  in  the  very  zenith  of  its  fame,  still  edited  by 


152  FUNCTIONS  OF  THE  LIVER.        [chap.  ix. 

the  accomplished  author  and  therefore  representing  the 
views  of  that  erudite  physician  and  physiologist;  in  the 
fourth  edition  published  in  1860,  will  demonstrate  most 
conclusively  the  advances  made  in  very  recent  years.  He 
places  the  secretion  of  bile  first,  as  might  be  expected 
from  that  time  of  day.  He  recognised  the  presence  of 
glycocholic  and  taurocholic  acids  in  union  with  soda;  but 
no  account  of  their  chemical  composition  is  given  to  throw 
light  upon  their  origin.  He  gives  the  process  of  secreting 
bile,  which  he  regards  as  "  constantly  secreted  for  tlie 
purification  of  the  blood  ; "  a  vague  phrase,  in  harmony 
with  the  general  vagueness  of  the  knowledge  of  that  time. 
He  recoo-nizes  bile  to  be  excrementitioics  and  digestive,  and 
that,  as  the  latter, — "bile  is  a  light  elaborated  fluid, 
formed  of  materials  which  do  not  pre-exist  in  the  same 
condition  in  the  blood,  and  secreted  by  cells  in  a  highly 
organised  gland  ;  "  nevertheless,  he  writes — "  The  general 
tendency,  however,  of  modern  observation  is  to  the  effect, 
that  bile  has  very  little  influence  on  the  process  of  diges- 
tion." He  adds — "The  bile,  however,  like  the  gastric 
fluid,  has  a  strongly  antiseptic  power,  and  may  serve  to 
prevent  decomposition  of  the  food  during  the  time  of  its 
sojourn  in  the  intestines."-  He  says — "Respecting  the 
nature  of  the  influence  exercised  by  the  bile  in  digestion, 
there  is,  however,  very  little  at  present  known.  It  is  sup- 
posed by  some,  that  the  bile  assists  in  converting  the 
chyme  into  chyle,  especially  by  emulsifying  the  fat,  and 
thus  rendering  it  capable  of  being  absorbed  by  the  lac- 
teals."  So  much  for  the  bile.  The  light  is  little  yet. 
He  goes    on—"  The    secretion    of  bile,  as  already  ob- 


CHAP.  IX.]        FUXCTIONS   OF  THE  LIVER.  153 

served,  is  only  one  of  the  purposes  fulfilled  by  the  liver. 
Another  very  important  function  appears  to  be  that  of 
so  acting  upon  certain  constituents  of  the  blood  passing- 
through  it,  as  to  render  some  of  them  capable  of  assimila- 
tion with  the  blood  generally,  and  to  prepare  others  for 
being  duly  eliminated  in  the  process  of  respiration.  From 
the  labours  of  M.  Bernard,  to  whom  we  owe  most  of  what 
we  know  on  the  subject,  it  appears  that  the  low  form  of 
albuminous  matter,  or  albuminose,  conveyed  from  the  ali- 
mentary canal  by  the  blood  of  the  portal  vein,  requires  to 
be  submitted  to  the  influence  of  the  liver  before  it  can  be 
assimilated  by  the  blood."  This  is  the  beginning  of  a  most 
important  matter  in  physiology,  or  rather  the  beginning  of 
the  recognition  of  the  matter,  viz.,  that  imperfectly  assimi- 
lated albuminoid  matter,  the  product  of  digestion  in  tlie 
gastro-intestinal  canal,  is  further  elaborated  by  the  liver, 
so  that  the  tissues  may  be  fed  therefrom.  The  liver  was 
recoo^nized  bv  M.  Claude  Bernard  as  being  connected  with 
the  higher  elaboration  of  the  albuminoid  constituents  of 
our  food  ;  by  it  the  peptones,  produced  by  the  digestive  act 
in  the  stomach  and  small  intestines,  are  further  fitted  to 
feed  the  blood,  and  from  it,  again,  the  tissues.  So  far  ! 
so  good  ! 

Dr.  Kirkes  also  recog-nized  the  relation  of  the  liver  to 
the  saccharine  materials  of  our  food.  "The  saccharine 
principles  of  the  food  undergo,  in  their  passage  through 
the  liver,  some  transformation  necessary  to  the  subsequent 
purpose  they  have  to  fulfil  in  relation  to  the  respiratory 
process,  and  without  which,  such  purpose  could  not  be 
properly  accomplished,  and  the  substances  themselves  would 


154  ■  FUNCTIONS   OF  THE  LIVER.         [chap,  ix. 

be  eliminated  as  foreign  matters  by  the  kidneys."  Thanks 
again  to  M.  Bernard,  some  light  was  breaking  upon  "gly- 
coo-en,"  or  "hepatic,"  or  "animal  starch,"  as  it  was  vari- 
ously termed  ;  and  its  utility  in  the  economy  of  the  body. 
They  have  also  begun  to  note  "  that  the  liver  possesses  the 
remarkable  property  of  forming  sugar  out  of  principles  in 
the  blood,  which  contain  no  traces  of  saccharine  or  amy- 
laceous matter."  This  was  a  step  forward.  It  was  seen 
that  the  liver  in  the  Carnivora,  constructs  sugar  out  of  the 
materials  of  their  food.  The  utility  of  sugar  as  the  respir- 
atory food  is  beginning  to  be  seen  ;  as  also  its  storage  in 
the  liver  from  intermittent  meals  for  constant  use.  Like 
the  granary  into  which  we  pour  our  corn  after  the  annual 
harvest,  and  from  which  we  take  it  again  for  our  daily 
wants  !  He  says  of  the  glycogen — "  It  manifests  a  remark- 
able tendency  to  pass  into  sugar  in  the  presence  of  an 
animal  ferment."  He  sums  up  thus — "The  liver  may  be 
regarded  as  an  organ  engaged  in  forming  two  kinds  of 
secretion,  namely  bile  and  sugar,  or  rather  the  glycogenic 
substance  readily  convertible  into  sugar.  The  experiments 
of  Lehmann  led  him  to  believe  that  the  liver-sugar  is  con- 
verted into  lactic  acid,  previous  to  being  finally  disposed  of 
in  respiration." 

From  this  we  see  that  in  1860  our  ideas  as  to  the  func- 
tion of  the  liver  were  beginning  to  take  shape  ;  that  chaos 
was  coming  into  some  approach  to .  order.  We  will  next 
see  how  Dr.  Murchison  arranged  the  order  of  the  different 
functions  of  the  liver  ;  and  how  much  a  few  more  years 
had  taught  us  upon  this  subject.  The  gigantic  stride 
made  between  1860  and  1874  will  tell  in  no  indistinct 


CHAT.  IX.]        FUNCTIONS   OF  THE  LIVER.  155 


language  the  light  modern  physiology  has  thrown  upon 
the  digestive  processes;  and  with  that  the  service  it  has 
rendered  to  practical  medicine. 

We  see  how  the  grand  physiologist  Claude  Bernard  was 
opening  up  for  us,  knowledge  of  incalculable  value  as  to 
dio-estion;  as  one  of  the  numerous  subjects  he  was  investi- 
gating. His  range  was  a  wide  one;  his  grip  was  as  tight 
as  his  grasp  was  extensive.  He  it  was,  above  all  others, 
who  has  forced  nature  to  reveal  some  of  her  most  impor- 
tant secrets;  and  we  must  all  be  grateful  to  him  accord- 
ingly— grateful  in  proportion  to  what  we  have  received 
from  him.  In  a  few  more  years  his  views  were  clearer, 
more  precise,  more  advanced.  Not  only  this:  but  they 
were  accepted  by  the  leading  physiologists,  especially  by 
Ludwig  of  Leipsic,  and  the  school  of  which  he  is  the  illus- 
trious and  honoured  head. 

"We  may  summarise  the  matter  as  standing  in  1860, 
something  near  this. 

1.  The  bile  was  not  merely  excrementitious  as  regards 
the  blood;  it  was  useful  in  the  digestive  act,  emulsifying  fat. 

2.  The  crude  albuminoid  products  of  digestion  in  the 
gastro-intestinal  canal  were  further  elaborated  in  the  liver, 
and  fitted  for  the  nutrition  of  the  tissues  of  the  organism. 

3.  The  saccharine  elements  of  our  food  underwent  some 
change  in  the  liver,  being  converted  into  glycogen,  or  ani- 
mal starch;  and  this  again,  in  the  presence  of  an  animal 
ferment,  was  once  more  transformed  into  sugar,  which 
was  burnt  in  the  blood. 

Further  that  the  liver  in  the  carnivora  could  form  this 
glycogen  from  the  albuminoid  elements  of  their  food. 


156  FUNCTIONS  OF  THE  LIVER.        [chap.  ix. 


The  physiologist  was  on  a  scent  which  lie  ran  upon 
rapidly  and  swiftly,  until  in  1874,  Dr.  Murchison  placed 
the  matter  as  follows.  We  will  note  the  day-break  passing 
into  morning  light,  in  further  acquaintance  with  the  utility 
of  bile;  the  relation  of  the  Hver  to  albuminoid  matters, 
both  constructively  and  destructively:  and  in  the  matter 
of  storage  of  glycogen.  The  importance  of  some  knowledge 
on  these  subjects  to  the  physician  in  his  every  day  w^alk  in 
life,  it  is  simply  impossible  to  over-estimate. 

The  first  thing  to  be  noted  is  the  change  in  the  ar- 
rangement. Instead  of  the  secretion  of  bile  it  is  the  "  gly- 
cogenic function  of  the  liver"  which  stands  first. 

"  The  most  valuable  contributions  towards  our  knowledge 
of  this  matter  have  been  the  researches  of  Claude  Bernard 
and  other  observers,  who  have  shown  that  the  liver  has 
the  power  of  making  and  storing  up  for  a  time  within  its 
cells  glycogen  (Cg  H^^  0,)  a  substance  resembling  dextrine 
(Cg  Hj^,  OJ,  in  its  chemical  composition  and  reaction,  and 
like  it  capable  of  conversion  into  sugar  by  the  action  of 
albuminoid  ferments.  This  substance  always  exists  in  the 
liver  in  larger  amounts  during  digestion,  than  during  fast- 
ing, attaining  its  maximum  usually  about  four  or  five 
hours  after  a  meal."  He  then  proceeds  to  show  that  gly- 
cogen when  present  in  excess  in  the  liver  may  be  converted 
into  fat.  (We  are  all  familiar  with  the  huge  fatty  liver  of 
the  goose  which  furnishes  pate  de  foie  gras).  Also  that 
glycogen  can  be  formed  by  the  liver  in  a  dog  fed  on  albu- 
minoid matters  alone,  and  that  the  decomposition  of  a 
peptone  produces  glycogen  and  the  nitrogenous  matters 
leucin  (0^  H^3  NOJ  and  tyrosin  (0,  H,,  NO3)  which  are 


CHAP.  IX.]        FUXCTIOXS  OF  THE  LIVER.  157 

ultimately  resolved  into  urea  (CH^  N^  O).  Not  only  does 
this  glycogenic  function  of  the  liver  supply  an  easily 
oxidisable  matter  readilv  converted  into  carbonic  acid  and 
water,  producing  heat  ;  but  there  are  good  grounds  for 
believina^  that  it  assists  in  cell-fjrowth.  Sug-ar  is  found  in 
the  cells  of  the  placenta,  in  foetal  tissues,  in  the  inflam- 
matory products  of  pneumonia,  and  in  new  growth  when- 
ever cell-formation  is  active.  Nor  is  this  confined  to 
animals  ;  the  same  occurs  in  plant  life." 

Further — '•  In  the  early  stages  of  foetal  life  the  blood- 
cells  multiply  throughout  the  entire  mass  of  blood  ;  but 
when  the  liver  begins  to  be  formed,  this  process  ceases, 
and  a  very  active  formation  of  colorless  blood-cells  is  set 
up  in  the  liver,  these  colorless  cells  undergoing  a  gradual 
change  by  the  development  of  coloring  matter  in  their 
interior  into  red  corpuscles.  According  to  Kolliker,  this 
new  formation  of  blood-corpuscles  in  the  liver  continues 
during  the  whole  of  the  foetal  life  of  the  mammalia.  The 
observations  quoted  above  make  it  probable  that  the  liver 
in  the  adult  continues  to  perform  the  functions  which  per- 
tain to  manv  different  tissues  of  the  foetus,  the  grlvcosren 
secreted  in  its  cells  combining"  with  nitroo^en  and  formino- 
an  azotised  protoplasm,  which  maintains  the  nutrition  of 
the  blood  and  tissues."  Further — "  The  process  of  assimi- 
lation may  soon  go  on  to  the  production  of  fat  in  the  liver, 
or  it  may  stop  short  at  the  formation  of  another  principle 
which  escapes  from  the  liver,  and  is  elsewhere  transformed 
into  fat.  Lastly,  there  are  good  grounds  for  thinking  that 
both  glycogen  and  sugar  serve  some  purpose  in  muscular 
action  ;  at  all  events,  it  has  been  found  that  the  quantity 


158  FUN-CTIONS   OF  THE  LIVER.         [chap.  ix. 

of  sugar  in  the  blood  becomes  greatly  diminished  in  passing 
through  the  vessels  of  contracting  muscles.  According  to 
Bernard  this  destruction  of  sugar  in  muscles  is  duie  to 
lactic  fermentation."  It  is  as  lactic  acid  that  sugar  is 
probably  burnt  in  the  organism. 

Galen  held  that  the  liver  was  eno^as^ed  in  sano-uification. 
Dr.  Murchison  holds  that  Galen  was  right;  and  proceeds — 
"  But  modern  research  has  made  it  probable  that  the  liver 
is  endowed  with  a  function  not  suspected  by  Galen,  and 
which  from  a  pathological  point  of  view  is  even  more  im- 
portant than  that  which  we  have  been  considering.  Many 
observations  pathological  as  well  physiological  point  to 
the  conclusion  that  the  liver  is  not  only  a  blood-forming  but 
a  blood-destroying  or  purifying  organ,  and  that  it  contri- 
butes in  a  great  degree  to  the  destruction  of  albuminous  mat- 
ter derived  from  the  food  and  textures,  and  the  formation  of 
urea  and  lithic  acid,  which  are  subsequently  eliminated  by 
the  kidneys.  First,  there  seems  to  be  little  doubt  that  the 
albumen  and  fibrin  of  the  blood  become  largely  disintegrated 
in  the  liver.  Lehmann  and  Bernard  have  shown  that  while 
the  portal  blood  contains  much  fibrin,  blood  from  the  he- 
patic vein  contains  little  or  none."  Further  he  writes — 
*'  Moreover  there  are  grounds  for  believing  that,  while 
white  blood-corpuscles  take  their  origin  in  the  liver,  the 
red  corpuscles  are  destroj'ed  there,  and  that  the  nitro- 
genous coloring  matters  of  the  urine  are  partly  the  result 
of  the  destructive  process." 

There  is  stronc:  evidence  of  the  destruction  of  albuminoid 
matters  in  the  liver.  It  is  the  grave  of  the  red  blood- 
corpuscles  ;  further  it  is,  in  all  probability,  the  furnace  in 


CHAP.  IX.]        FUNCTIONS  OF  THE  LIVER.  159 

-vvhicli  all  forms  of  albuminoid  waste  are  oxidised  into  the 
ultimate  product  urea,  which  is  cast  out  by  the  kidneys. 

He  then  gives  observations  from  various  authorities,  and 
writes  :  "  It  is  important  to  add,  that  the  formation  of  urea 
in  the  liver  is  always  greatly  increased  after  food.  Lithic 
acid  has  also  been  found  repeatedly  in  the  liver  of  man 
and  mammalia,  but  always  in  small  quantity;  whereas,  in 
birds,  in  which  lithic  acid  takes  the  place  of  urea,  as  the 
great  eliminator  of  nitrogen,  it  also  takes  the  place  of  urea 
in  the  liver,  as  it  probably  does  in  the  human  liver  under 
certain  pathological  conditions.  All  these  observations 
point  to  the  liver  as  being  largely  concerned  in  the  de- 
structive metamorphosis  of  albuminoid  matter,  the  pro- 
ducts of  which  are  eliminated  by  the  kidneys  ;  although 
it  is  not  improbable  that  other  glandular  organs,  and  even 
the  corpuscles  in  the  circulating  blood,  as  believed  by 
II.  Ludwig  and  Fuhrer,  may  contribute  to  the  process." 
A  certain  amount  of  body-heat  is  formed  by  these  pro- 
cesses going  on  in  the  liver.  Again,  Galen  is  corroborated 
in  his  opinion,  "that  the  liver  is  a  great  centre  of  animal 
heat." 

This  second  function  of  the  liver,  namely,  the  oxidation 
of  waste  and  surplus  nitrogenised  material,  is  one  of  the 
g'reatest  moment  in  the  treatment  of  liver-derangements. 
It  is  in  the  metabolism  of  albuminoids  that  we  iind  the 
origin  of  many  maladies. 

Dr.  Murchison  writes:  "  The  third  function  of  the  liver 
is  the  secretion  of  bile.  The  composition  of  this  substance  is 
complex,  and  its  uses  are  not  yet  sufficiently  known."  The 
colouring  matter  of  bile  is  formed  from  hremoglobin  "by 


160  FUNCTIONS   OF  THE  LIVER.        [chap.  ix. 

the  hepatic  cells,  in  the  passage  of  the  blood  through  the 
liver."  Then  again,  "  There  are,  on  the  other  hand, 
grounds  for  believing  that  bile-pigment  is  in  its  turn 
converted  into  urinary  pigment.  It  is  also  a  well-known 
clinical  fact,  that  nothing  influences  so  much  the  charac- 
ters of  the  urinary  pigment  as  functional  or  structural 
disease  of  the  liver."  Blood-pigment  is  first  converted 
into  bile-pigment,  and  finally  into  urinary  pigment. 

The  important  matters  of  bile  are  the  two  bile-acids  in 
union  with  soda.  "  The  bile-acids  in  human  bile  are 
two — glycocholic  acid  (C^gH^gNO^)  and  taurocholic  acid 
(CjgH^^NO^S).  Both  acids  are  derivatives  of  albumen  and 
contain  nitrogen  ;  and  taurocholic  acid,  to  which  the  bitter 
taste  of  the  bile  is  due,  contains  all  the  sulphur  of  the  bile. 
Both  are  in  bile  combined  with  soda,  and  both  are  what 
are  called  conjugate  acids  ;  that  is  to  say,  they  are  com- 
posed of  choiic  acid  (C^^H^^OJ,  which  contains  neither  ni- 
trogen nor  sulphur,  in  combination  with  taurin  (C„H^NO^S) 
which  contains  both  nitrogen  and  sulphur,  and  glycocin 
(C2H5NO2)  which  contains  nitrogen  but  no  sulphur."  In 
the  bile  is  found  also  a  fatty  substance  cholesterin  (C^^H^^O), 
the  main  constituent  of  gall-stones.  "The  amount  of 
bile  secreted  by  the  liver  has  been  shown  experimentally 
to  increase  suddenly  after  a  meal,  reach  its  maximum  in 
about  two  hours,  and  then  gradually  decline  ;  while  by 
abstinence  it  is  greatly  lessened."  Of  this,  but  a  very 
small  portion  is  expelled  by  the  bowels.  "  A  large  propor- 
tion of  the  bile  secreted  by  the  liver  is  again  absorbed, 
either  by  the  biliary  passages,  or  by  the  mucous  membrane 
of  the  bowels.     From  what  is  now  known  of  the  diffusi- 


CHAP.  IX.]        FUNCTIONS  OF  THE  LIVER.  161 

bility  of  fluids  through  animal  membranes,  it  is  impossible 
to  conceive  bile  long  in  contact  with  the  lining  membrane 
of  the  gall-blader,  bile  ducts,  and  intestines,  without  a 
large  portion  of  it  passing  into  the  circulating  blood.  The 
constant  secretion  and  re-absorption  of  bile  is,  in  fact, 
merely  part  of  that  osmotic  circulation  constantly  taking 
place  between  the  fluid  contents  of  the  bowel  and  the 
blood,  the  existence  of  which  is  too  little  heeded  in  our 
pathological  speculations,  and  in  therapeutics."  Further, 
"  How  many  times  this  cycle  of  movement  is  repeated, 
before  the  bile  is  extruded  from  the  system,  we  have  no 
means  of  knowing;  but  in  the  course  of  the  osmotic  circu- 
lation, much  of  the  bile  appears  to  become  transformed  in- 
to products  which  are  eliminated  by  the  lungs  and  kidneys; 
while  at  the  same  time  this  circulation  assists  in  the  as- 
similation of  the  nutritive  materials  derived  from  the  food. 
In  the  first  place  it  assists  in  the  absorption  of  fat.  It  is 
a  well-knowu  clinical  fact  that,  when  the  common  bile- 
duct  becomes  obstructed  from  any  cause  in  man,  the  fat 
throughout  the  body  wastes."  It  is  also  excrementitious 
in  that  it  contains  materials,  which  by  conversion,  are  cast 
out  of  the  body  as  excrementitious  matter.  Further,  bile 
stimulates  the  peristaltic  action  of  the  bowel  and  prevents 
putrefaction  in  the  intestines. 

Dr.  Murchison  sums  up  thus  : 

"  From  what  has  been  stated,  it  follows  that  the  func- 
tions of  the  liver  may  be  summed  up  under  three  heads, 
viz.: 

*'  1.  The  formation  of  gl^^cogen,  which  contributes  to  the 
maintenance   of  animal  heat,  and  to  the  nutrition  of  the 


162  FUNCTIONS   OF  THE  LIVER.        [chap.  ix. 

blood  and  tissues;  and  the  development  of  white  blood- 
corpuscles. 

"2.  The  destructive  metamorphosis  of  albuminoid  matter, 
and  the  formation  of  urea  and  other  nitrogenous  products, 
which  are  subsequently  eliminated  by  the  kidneys,  these 
chemical  interchanges  also  contributing  to  the  develop- 
ment of  animal  heat. 

"  3.  The  secretion  of  bile,  the  greater  part  of  which  is 
reabsorbed,  assisting  in  the  assimilation  of  fat  and  pep- 
tones, and  probably  in  those  chemical  changes  which  go  on 
in  the  liver  and  portal  circulation;  while  part  is  excre- 
mentitious,  and  in  passing  along  the  bowel,  stimulates 
peristalsis  and  arrests  decomposition." 

Such  is  where  Dr.  Murchison  leaves  the  subject  in  1874. 
The  advance  made  during  these  fourteen  years  from  1860 
to  1874  was  mainly  due  to  the  labours  of  Claude  Bernard, 
whose  death  has,  for  a  time,  checked  the  enquiry.  Others 
are  makincr  themselves  certain  .about  the  facts  and  then 
progressing. 

This  summary  throws  much  light  upon  many  matters  of 
great  clinical  interest.  Certainly  derangement  in  the  gly- 
cogenic function  of  the  liver  gives  us  diabetes;  but  the 
derangements  of  the  liver  are  mainly  connected  with  the 
metabolism  of  albuminoids.  And  this  fact  is  a  matter  the 
practical  physician  must  keep  clearly  in  his  mind's  eye, 
w^ell  focussed  and  distinct,  in  his  plan  of  treatment,  in  the 
interests  alike  of  the  patient  and  himself. 

Such  summary  brings  us  up  pretty  well  to  our  time,  and 
gives  the  reader  the  results  of  years  of  patient  investiga- 
tion, in  a  condensed  form,  convenient  for  his  use.     We 


CHAP.  IX.]        FUNCTIONS  OF  THE  LIVER.  163 

recoo-nise  then  that  the  liver  is  the  storehouse  of  our  fuel 
food,  in  the  form  of  glycogen.  This  is  converted  into 
sugar  as  is  required  for  the  wants  of  the  organism,  by  a 
ferment  in  the  liver  itself.  It  is  the  same  process  in  the 
body  as  in  the  plant.  The  plant  digests  its  stpred  starch 
as  it  requires,  by  first  converting  it  into  sugar.  The  liver 
takes  from  its  store  of  glycogen  as  it  requires  for  the  wants 
of  the  body.  By  such  means  a  regular  supply  of  sugar  is 
furnished  to  the  blood.  Upon  this  subject  our  information 
is  fairly  explicit. 

As  to  the  second  function  of  the  liver  we  have  much  to 
learn.  We  recoo'nise  its  action  in  tlie  destruction  of  waste 
and  surplus  albuminoids;  we  see  that  urea  is  formed  by 
the  liver,  not  by  the  kidneys;  we  begin  to  see  that  lithiasis, 
or  lithsemia  is  primarily  a  derangement  of  the  liver,  and 
that  the  waste  matter  in  the  blood  produces  in  time  struc- 
tural changes  in  the  kidney;  we  can  see  that  when  oxida- 
tion is  imperfect  the  nitrogenous  matters  suffer  most.  All 
this  we  discern.  But  what  we  do  sincerely  desire  to  know 
more  about  is — the  further  elaboration  of  the  proteid 
matters  which  have  been  converted  into  peptones  in  the 
diofestive  canal.  The  liver  has  to  do  with  this  matter. 
A  further  elaboration  goes  on  in  the  liver,  and  disturbance 
in  the  liver  leads  to  malnutrition.  Further  it  seems  very 
probable  that  the  huge  gland  is  a  filter,  allowing  certain 
nutritive  matters  to  pass  onward,  while  arresting  other 
matters  whose  presence  in  the  blood  is  deleterious.  Dr. 
Lauder  Brunton,  F.R.S.,  wrote  (Oct.  1880),  "It  seems  not 
at  all  unlikely,  then,  that  the  liver  has  got  another  func- 
tion besides  those  usually  assigned  to  it,  viz.,  that  of  pre- 


164  FUNCTIONS  OF  THE  LIVER.        [chap.  e. 

venting  the  digestive  ferments  from  reaching  the  general 
circulation  so  as  to  act  upon  the  tissues."  This  is  a  very 
interesting  subject — this  capacity  of  the  liver  to  confine 
the  digestive  ferments  to  their  own  proper  domain  where 
they  are  eminently  useful;  and  preventing  their  emergence 
therefrom  into  the  general  circulation  where  they  would 
in  all  probability  be  distinctly  harmful. 

It  would  appear  also  that  peptones  when  escaping  into 
the  general  circulation  are  depressant  agents.  I  will 
quote  Dr.  Brunton  again — "  Professor  Albertoni  has  found 
that  peptones  have  a  most  remarkable  action  upon  the 
blood,  completely  destroying  the  coagulability  in  dogs, 
while  they  have  little  power  in  this  respect  over  the  blood 
OK  rabbits  and  sheep.  He  and  Dr.  Schmidt-Mtihlheim 
independently  made  the  discovery  that  peptones  prevented 
the  coagulation  of  the  blood  in  dogs,  and  the  latter,  under 
Ludwig's  direction,  has  also  investigated  their  action  upon 
the  circulation.  He  finds  that  when  injected  into  the  veins, 
they  greatly  depress  the  circulation,  so  that  the  blood- 
pressure  falls  very  considerably;  and  when  the  quantity 
injected  is  large,  they  produce  a  soporose  condition,  com- 
plete arrest  of  the  secretion  by  the  kidneys,  convulsions 
and  death.  From  these  experiments  it  is  evident  that  the 
normal  products  of  digestion  are  poisons  of  no  inconsider- 
able power,  and  that  if  they  reach  the  general  circulation 
in  large  quantities  they  may  produce  very  alarming,  if  not- 
dangerous  symptoms."  It  would  appear  that  in  certain 
conditions,  as  a  consequence  of  disturbance  in  the  working 
of  the  liver,  the  organism  is  not  only  ill-fed  from  the 
absence  of  normal  products  of  assimilation,  but  is  actually 


CHAP.  IX.]        FUNCTIONS  OF  THE  LIVER. 


165 


poisoned  by  the  presence  of  products  which  are  positively 
huriiiful.  Here  there  are  blended  the  evidences  of  aniemia 
and  toxaiinia.  No  wonder  then  that  nervous  depression  is 
found  along  with  indigestion. 

"  The  action  of  digestive  ferments  is  just  beginning  to 
find  a  practical   application    in   medicine,  and  sometimes 
undoubtedly  they  are   of  very  great  service;  but  unless 
their  action  is  investigated  more  thoroughly  than  it  has 
been  up  to  the  present,  it  is  just  possible  that  we  may  find 
that  the  digestive  ferments,  like  all  other  powerful  agents, 
may  do  much  harm  as  well  as  good."      This  is  a  useful 
hint  from  Dr.  Brunton  to  the  effect  that  "children  should 
not  play  with  edged   tools."     The  indiscriminate  use  of 
artificial  digestive  ferments  may  do  for  them  what  indis- 
criminative  use  has  done  for  many  a  useful  agent,  viz., 
bring  them  into  disrepute.    ^Ye  must  use  these  agents  with 
all  the  knowledge  and  skill  we  can  bring  to  bear  upon  them 
—wielding  them  discreetly.     It  seems  possible  that  in  some 
cases  and  under  certain  conditions,  they  might  act  injurious- 
ly.    But  granting  this,  we  must  not  be  deterred  from  resort 
to  them  for  the  relief  of  evils  we  know,  by  the  possible  exist- 
ence of  hypothetical  drawbacks.  It  is  well,  however,  to  bear 
the  matter  in  mind  so  far  as  not  to  forget  such  a  possibility. 
But  to  return  to  the  more  strictly  proper  subject  matter 
here,  and  follow  Dr.  Brunton  a  little  further:— "  And  now 
comes  the  question.     How  is  it  that  ni  healthy  conditions 
of  the  intestine,  peptones  do  not  pass  into  the  general  cir- 
culation, and  are  therefore  unable  to  exert  any  poisonous 
action  upon  the  nerve-centres?     This  question  is  one  we 
cannot  at  present  answer  quite  satisfactorily.     Usually  the 


166  FUNCTION'S  OF  THE  LIVER.         [chap.  ix. 

peptones  disappear  from  the  portal  blood  before  it  reaches 
the  general  circulation.  Indeed  Ludvvig  and  Schmidt- 
Muhlheim  found  that  even  in  the  portal  blood,  before  it 
reaches  the  liver,  very  little  if  any  peptone  is  to  be  found. 
They  have  not  succeeded  in  discovering  where  the  peptone 
undergoes  change.  Plosz  and  Gergyai,  and  also  Drosdorff, 
have  discovered  peptone  in  the  blood  of  the  portal  vein; 
and  Plosz  and  Gergyai  have  been  led  by  their  experiments, 
to  regard  the  liver  as  the  seat  of  the  transformation  of  pep- 
tones. In  consideration  of  the  more  recent  experiments  of 
Ludwig  and  Schmidt-Miihlheim,  we  cannot  entirely  adopt 
the  views  of  these  authors,  though  it  is  nevertheless  possi- 
ble that  they  are  to  a  certain  extent  right,  and  that  the 
liver,  to  some  extent  at  least,  serves  the  purpose  of  prevent- 
ilig  any  peptones  from  getting  into  the  general  circulation, 
which  may  have  escaped  transform.ation  in  the  portal 
blood  before  reaching  it."  Such  then  is  our  very  latest 
information  on  the  n:iatter.  There  is  digestion,  there  is 
also  a  filtering  process  in  health.  We  may  suffer  that 
form  of  indigestion  known  as  "  biliousness,"  either  from 
imperfection  in  the  elaboration  of  the  products  of  digestion 
in  the  gastro-intestinal  canal,  or  from  imperfection  in  the 
filtering  process.  In  either  case  the  system  is  ill-fed,  and 
at  the  same  time  poisoned  by  the  want  of  certain  consti- 
tuents, and  the  presence  of  others  in  the  blood.  The  liver 
then  is  a  most  important  organ  in  the  elaboration  of  the 
products  of  digestion,  as  well  as  in  the  destruction  by  oxi- 
dation of  waste  and  surplus  albuminoid  material.  Disor- 
der of  the  liver  then  will  give  us  maladies,  of  which  some 
account  will  be  f  urnislied  in  the  ensuing  chapter. 


CHAPTER  X. 

THE  PHENOMENA  OF  LIVER  DISTURBANCE. 
BILIO  USNESS. 

From  what  has  been  said  in  the  preceding  chapter  as  to 
the  function  of  the  liver,  the  reader  will  be  prepared  for  an 
explanation  of  certain  well-known,  and  equally  well-marked 
clinical  phenomena. 

It  is  quite  a  common  experience,  with  children  espe- 
cially, to  see  an  acute  "  bilious  attack  "  follow  free  indul- 
gence in  rich  food.  Some  children  are  "  upset  "  by  what 
are  quite  ordinary  means  with  other  children.  Even  a 
little  rich  cake  is  sufficient  in  some  to  disturb  the  dio-es- 
tive  system,  to  produce  nausea  with  headache,  followed 
by  actual  vomiting,  giving  great  relief,  and  sometimes  by 
purging  ;  after  which  the  child  resumes  its  wonted  state 
of  health.  Every  medical  man  of  any  experience  at  all 
has  seen  this  over  and  over  a2:ain.  About  the  clinical 
facts  no  doubt  or  difference  of  opinion  obtains.  But  about 
the  explanation  a  wide  difference  will  be  noted  in  the 
opinions  founded  upon  these  data.  I  mean  the  more  re- 
mote, not  the  obvious  explanation.  The  mother  of  the 
child  will  tell  vou,  with  the  most  unhesitatino-  confidence, 
that — "  it  was  the  sweets,  and  the  rich  cake.  Anything 
too  rich,  either  with  sugar  or  butter,  always  upsets  that 
child  !  "  The  old  family  doctor  nods  his  venerable  head  in 
complaisant  harmony;  and  "that  child"  is  carefully 
watched   in  the  future  as   to  its   eating,  especially  with 


168  LIVER  BISTURBANCE.  [chap.  x. 

reference  to  saccharine  and  fatty  food,  in  anything  like 
excess. 

Yet  this  theory,  however  widely  accepted,  contains  a 
fallacy;  and  it  is  important  in  the  interest  of  that  child, 
of  other  -children  similarly  circumstanced,  and  indeed  in 
the  interest  of  a  number  of  adults,  that  this  matter  be 
thrashed  out.  The  fallacy  is  one  which  only  revealed 
itself  when  chemistry  explained  the  composition  of  bile; 
previous  to  that  epoch,  the  fallacy  lay  too  well-concealed  to 
be  suspected  to  be  a  fallacy.  The  relations  of  cause  and 
effect  were  too  clear  for  a  scintilla  of  doubt  to  suggest 
itself.  Nevertheless  a  fallacy  does  underlie  these  familiar 
clinical  phenomena. 

From  what  was  said  in  the  last  chapter,  it  is  abundantly 
clear  that  it  is  the  metabolism  of  albuminoids  in  the  liver 
which  caused  these  disturbances.  The  readily  oxidisable 
hydrocarbons  burn  up  quickly  without  trouble,  unless  it  is 
the  heart-burn  excited  by  some  fatty  acid  in  the  stomach. 
As  said  before,  Liebig  pointed  out  that  the  union  of  nitro- 
gen with  other  elements,  interfered  with  the  ready  oxida- 
tion of  the  compound  so  formed.  The  albuminoid  tissues 
of  the  body  do  not  themselves  burn,  while  the  fuel-food 
burns  in  them;  just  as  the  works  of  a  steam  engine  do 
not  burn  with  the  coals  burning  in  the  furnace.  It  is  the 
albuminoids,  which  in  their  underground  hidden  career, 
from  peptones  to  bile  acids  and  urine  solids,  which  cause 
the  troubles  of  the  liver.  The  filtering  of  peptones,  the 
elaboration  of  albuminoids,  the  construction  of  white  cor- 
puscles, the  relations  of  the  liver  to  matters  for  histogenesis 
on  the  one  hand;  its  relations  to  histolysis  on  the  other; 


CHAP.  X.]  LIVER  DISTURBANCE.  169 

its  being  the  fui-uace  in  wliich  waste  and  surplus  nitro- 
genized  material,  old  elTeto  blood- corpuscles,  arc  burnt  ; 
and  the  luxus  consumption  of  albuminoids  which  are  split 
up  into  fat  and  urea  ;  these  are  the  matters  which  cause 
those  disturbances  of  health,  which  we  recognize  as  asso- 
ciated with  "the  liver."  In  the  form  of  the  acute  bilious 
attack  here  described,  it  is  the  second  part  of  the  function 
of  the  liver  which  is  involved,  viz.,  the  oxidation  of  waste 
and  surplus  nitrogenized  matters.  The  attack  is  the  old- 
fashioned  "  surfeit,"  that  is,  a  meal  where  the  palate  is 
followed  regardless  of  the  wants  of  the  body  ;  in  other 
words  the  individual  eats  more  than  is  good  for  him,  or 
her,  as  it  is  in  delicate  girls  this  trouble  is  most  frequently 
seen  ;  while  it  is  boys,  rather,  who  are  given  to  eating  to 
excess.  An  excessive  quantity  of  food  is  taken  and  the 
assimilative  organs  are  upset  thereby.  Unless  a  portion 
of  the  inordinate  meal  be  got  rid  of  by  vomiting,  or  by 
purging,  it  is  by  oxidation  that  it  must  be  removed.  All 
are  familiar  with  the  very  sharp  pyrexia,  the  sudden  and 
marked  rise  of  body  temperature  which  accompanies  acute 
indiofestion.  The  svstem  is  holdino;  a  bonfire  to  the  o-reat 
discomfort  of  the  child,  the  dismay  of  its  mother  and  nurse, 
and  the  benefit  of  the  family  doctor  !  An  emetic,  a  dose  of 
laxative  medicine  containing  a  mercurial,  and  the  attack 
is,  usually,  soon  over  without  any  future  consequences. 
In  a  few  instances  the  liver  remains  irritable,  and  is  easily 
upset  b}'^  any  error  in  diet  for  some  time  afterwards  ;  a  con- 
dition to  which  the  term  "  bilious  fever  "  was  applied  by  a 
past  generation. 

Now  this  acute  bilious  attack  is  undoubtedly  preceded  by 


170  LIVER  DISTURBANCE.  [chap.  x. 


indulgence  in  rich  food,  by  which  is  usually  meant  sugar 
and  butter;  but  it  will  not  do  to  overlook  the  eggs  used  in 
the  preparation  of  *' good  things  "  in  which  the  youthful 
appetite  delights. 

This  view  of  the  maternal  parent  and  the  family  doctor 
is  quite  in  harmony  with  the  views  held  by  persons  more 
widely,  and  more  specially  informed  than  they  were,  or 
professed  to  be.  Even  Liebig  thought  that  bile  was  formed 
from  the  hydrocarbonaceous  elements  of  our  food  ;  follow- 
ing the  formula  for  cholic  acid  iS^^J^iS^h)-  ^on  Gorup- 
Bessanez  held  the  same  view  ;  "  and  it  was  a  favorite 
theory,  some  five  and  thirty  years  ago,  that  the  bile 
was  derived  chiefly  from  the  decomposition  of  the  fats; 
in  fact,  a  return  to  a  much  older  belief  that  the  bile  was 
a  kind  of  soap."  In  1852,  in  an  article  published  hj 
Bidder  and  Schmidt,  doubts  were  cast  on  this  hypothesis. 
*'  Bidder  and  Schmidt,  however,  noticed  that  upon  an 
exclusive  diet  of  fat,  the  secretion  of  bile  at  once  fell  to  the 
level  of  that  in  an  animal  from  whom  all  food  was  with- 
drawn ;  so  that  they  think  that  the  nitrogenous  elements 
of  the  food  must  be  looked  on  as  the  chief  source  of  the 
bile."  To  follow  the  subject  further — ■''^  H.  Nasse  in  his 
earlier  work  saw,  however,  a  great  increase  of  the  secretion 
of  bile,  when  with  fat  nitrogenous  foods  were  also  given. 
Ritter  found  that  in  a  dog  fed  only  on  potatoes,  or  on  po- 
tatoes and  fat  only,  the  amount  of  bile  daily  excreted  fell 
very  low."  These  are  important  observations  pregnant 
with  information  as  to  the  dietary  which  excites  "  bilious- 
ness." These  quotations  are  made  from  the  learned  trea- 
tise of  Dr.  Wickham  Legg  on  "  Bile,  Jaundice,  and  Bilious 


CHAP.  X.]  LIVER  DISTURBANCE.  171 


Diseases,""  1880;  a  perfect  storeliouse  of  iiifonnatiou  and 
research,  to  wliicli  reference  will  frequently  be  made  in  this 
chapter.  One  further  quotation  will  illustrate  even  more 
clearly  the  point  I  am  driving  at,  as  to  the  source  of  the 
bile.  *'  The  amount  of  nitrogen  in  glycocol,  and  of  nitro- 
gen and  sulphur  in  taurin  would  certainly  seem  to  point  to 
an  origin  in  the  albuminous  bodies  of  the  blood  or  food. 
Some  part  of  these  bodies  is  thought  to  be  split  up  in  the 
liver  into  taurin  and  glycocol,  while  another  part  goes  to 
form  leucin,  tyrosin,  xanthin  and  hypoxanthin-bodies  con- 
taining nitrogen.  Meisner  would  probably  go  a  step  further, 
and  say  that  urea  also  was  formed  abundantly  in  the  liver. 
Do  the  peptones  at  once  furnish  these  nitrogenous  bodies, 
or  are  they  derived  from  the  products  of  the  decomposition 
of  the  tissues  ?  Karl  \^oit  would  answer  that  the  bile  acids, 
are  derived,  like  the  urea,  from  the  tissues,  while  the 
great  dependence  of  the  bile-making  functions  upon  the 
glycogenetic  function  would  seem  rather  to  suggest  that 
they  come  immediately  from  the  splitting  up  of  the  pep- 
tones." 

We  may  make  bricks  without  straw,  but  we  cannot  make 
them  without  mortar  !  The  nitrogenised  elements  in  the 
bile-acids,  to  say  nothing  of  the  sulphur  in  taurin,  point 
conclusively  to  their  origin  from  the  albuminoids  of  our 
food.  There  is  no  evading  that  conclusion;  unless  we 
assume  that  the  animal  body  builds  up,  by  sj^nthesis,  com- 
plex substances  containing  nitrogen,  from  hydrocarbons; 
an  hypothesis  which  will  not  hold  water  for  one  moment. 
The  complex  haemoglobin  and  lecithin  are  necessarily  built 
up  in  the  animal  body;    but  as  regards  the  ordinary  mat- 


172  LIVER  DISTURBANCE.  [chap.  x. 

ters  there  is  '^metabolism"  not  "construction;"  and  this 
metabolism  results  in  destructive  metamorphosis  by  oxida- 
tion. 

The  explanation  should  stand  so: — (1)  There  is  an  over- 
abundance of  food  taken;  (2)  the  more  readily  oxidisable 
hydrocarbons  burn  first;  (3)  leaving  the  less  readily  com- 
bustible albuminoids  to  be  burnt  as  best  may  be.  It  is  this 
residuum  of  nitrogenised  material  which  produces  the 
excess  of  bile,  with  the  general  disturbances  produced 
therefrom.  The  rich  food  is  the  cause  of  the  bile,  but  not 
"directly,"  only  "indirectly."  The  importance  of  this 
distinction  is  this,  erroneous  hypothesis  leads  to  an  impro- 
per dietary;  the  correct  theory  suggests  the  appropriate 
dietary.  "  Ritter  found  that  in  a  dog  only  fed  on  potatoes, 
or  on  potatoes  and  fat  only,  the  amount  of  bile  daily 
secreted  fell  very  low."  Yes;  that  is  it  !  On  a  non-nitro- 
genised  dietary,  or  one  containing  very  little  nitrogen 
indeed,  the  amount  of  bile  produced  was  very  small.  This 
is  the  secret  of  the  successful  treatment  of  Biliousness.  In 
the  PMladelpliia  3IecUcal  Times  for  June  23rd,  1877,  isaii 
article  on  "Biliousness  and  its  Management "  by  the  writer. 
As  a  more  extended  experience  merely  corroborates  what 
is  there  stated,  it  may  be  well  to  quote  from  this  article, 
which  shows  that  the  views  expounded  here  have  not  been 
hastily  seized  upon,  but  are  the  outcome  of  protracted 
thought;  and  are  sustained  by  an  experience  extending 
over  a  number  of  years.  "The  next  matter  is  to  see 
what  bearing  the  details  given  above  have  upon  the  right 
treatment  of  the  condition  of  biliousness.  I  am  of  opinion 
that  they  throw  a  whole  flood  of  light  upon  the  treatment, 


CHAP.  X.]  LIVER  DISTURBANCE.  173 

both  dietetic  and  medicinal.  They  lead  to  conclusions 
somewhat  different  from  what  are  generally  held,  especially 
about  the  ordinary  bilious  attack — that  is  where  the  bile- 
acids  are  the  chief  matter.  It  has  been  held,  and  is  yet  too 
much  held  in  reference  to  these  persons,  that:  'as  a  rule 
those  articles  of  diet  are  most  apt  to  disagree  which  con- 
tain much  saccharine  or  oleaginous  matter,  and  not,  as 
might  perhaps  have  been  expected,  nitrogenous  food,  plainly 
cooked.'  On  this  matter  I  am  at  issue  with  Dr.  Murchison. 
I  have  seen  bilious  individuals  who  asserted  that  they 
could  only  take  a  little  lean  meat,  bread,  and  tea,  getting 
no  better,  but  worse,  on  this  dietary;  who  were  all  the  bet- 
ter for  a  dietary  exclusively  hydrocarbonaceous.  Of  course 
they  commenced  with  the  full  expectation  of  being  much 
worse,  but  were  agreeably  surprised  to  find  themselves 
better.  In  realit}^  these  people  had  worked  in  a  wrong 
direction,  and  took  the  things  they  should  have  avoided,  and 
avoided  the  things  they  should  have  taken.  Of  course  it 
is  true  that  anv  indul^-ence  in  saccharine  or  oleaofinous  food 
in  addition  to  their  ordinary  food  made  them  worse;  but 
how  that  is  brought  about  has  been  explained  above. 
They  never  tried  to  do  without  their  albuminoid  food,  and 
tliat  is  the  point."  What  was  written  as  my  experience  in 
1877  remains  my  experience  still  in  1881. 

The  chemical  composition  of  the  bile-acids  points  to 
their  origin  in  the  albuminoids  ;  the  application  of  this  to 
practical  medicine  gives  satisfactory  results.  I  discussed 
the  matter  with  some  of  our  best  authorities,  including- 
Dr.  Murchison,  who  recognised  the  importance  of  the 
subject,  at  that  time;  and  their  agreement  with  my  own 


174  LIVER  DISTURBANCE.  [chap.  x. 

view  was  almost  complete.  The  lessons  taught  us  by -the 
liver  disorders  of  hot  climates  is  eminently  suggestive. 
To  quote  again  from  the  article  above: — "  And  again  the 
subject  of  indulgence  in  nitrogenised  food  crops  up.  If 
in  the  tropics,  fruit,  vegetables,  oils,  and  other  hydrocar- 
bonaceous  food  alone  be  taken,  the  liver  is  not  so  dis- 
ordered as  when  meat  is  added.  It  is  the  second  function 
of  the  liver  which  is  so  serious  a  matter  in  hot  climates; 
and  there  and  elsewhere  the  best  way  to  give  physiological 
rest  to  a  disturbed  liver,  is  to  relieve  it  as  far  as  possible 
from  the  labour  of  disintegrating  albuminoid  matter.  It 
apparently  taxes  the  liver  little  to  store  up  glycogen  and 
give  it  out  again;  but  the  breaking  up  of  nitrogenised 
bodies  is  the  labour  which  tests  it  most  severely.  In  trop- 
ical climates,  then,  hydrocarbonaceous  food  should  form 
the  staple  of  diet;  and  that,  too,  only  in  stinted  quantities 
by  those  whose  livers  are  unequal  to  high  functional  ac- 
tivity." 

If  this  was  made  the  rule,  then,  the  amount  of  bile  would 
be  reduced,  as  in  the  case  of  Ritter's  dog.  There  would 
just  be  that  amount  of  bile  which  is  required  for  the  emul- 
sionising  of  the  fat,  enough,  that  is;  and  no  surplusage  to 
disorder  the  system.  Those  Europeans  who  follow  the 
habits  of  the  natives  as  to  the  avoidance  of  meat  and 
alcohol,  know  comparatively  little  of  bilious  disorder;  and 
do  not  develop  that  bronzed  look  which  used  to  be  asso- 
ciated with  a  Nabob,  i.e.,  that  individual  of  marvellous 
constitution  and  vitality,  who  survived  an  Indian  experi- 
ence and  returned  to  his  native  shores,  a  curiosity  in  every 
way.    The  returned  East  Indian  now  is  not  distinguishable 


CHAP.  X.]  LIVER  DISTURBANCE.  175 

from  the  ordinary  Briton.     What  one  man  may  do  with 
impunity,  is  forbidden  to  others.     Some  persons  can  eat 
meat  and  drink  bottled  beer,  to  say  nothing  of  "  pegs  "  of 
brandy  and  soda,  and  yet  live  and  work  in  Bengal;  but 
they  do  not  run    thirteen    to  the   dozen.     "While  most  of 
those  who   try  to   do  this  are   overtaken   by  a  nemesis  in 
the  shape  of  liver  disorder,  which  interferes  most  materi- 
alh'  with  their  bodily  comfort  and  their  power  of  work.      So 
it  is    at    home:  there    are   individuals,  adults    as  well    as 
children,  who  are  upset  by  what  would  not  be  regarded 
as  indulgence  by  others,  and  which  can  be  taken  by  them 
with  impunity.     After  reviewing  the  production  of  bilious 
attacks,  the  article  proceeds: — "From  this  consideration 
of  the  production  of  an  ordinary  bilious  attack  in  a  fairly 
liealthy  person,  it  is  comparatively  easy  to  proceed  to  the 
consideration  of  the  production  of  allied  bilious  attacks  in 
those  who  are  abnormally  liable  to  them.     Dr.  Murchison 
repeats   the   thoughtful    suggestion   that    'most   persons 
have  more  liver,  just  as  they  have  more   lung,  than  is  ab- 
solutely necessary  for  the  due  performance  of  its  function. 
But   in   others,  not  unfrequently  the   offspring  of  gouty 
parents,  the   organ  in  its  natural  condition   seems   only 
just  capable  of  performing  its  healthy  functions  under  the 
most  favourable   circumstances,   and  functional   derange- 
ment  is  at   once  induced  bv  articles  of   diet   which  most 
persons  digest  with  facility.'     In  those  persons  with  livers 
which  if  not  abnormally  small  in  size,  are  of  limited  func- 
tional power,  bilious  disturbances  are    readily  produced; 
just  as  they  are  in  persons  whose  livers   are  crippled  by 
organic  disease."     All  are  familiar  with  instances  of  indi- 


176  LIVJER  DISTURBANCE.  [chap.  x. 

viduals  who  have  suffered  from  bilious  disturbance  in  India, 
who  come  home  and  are  fairly  well;  but  if  they  venture 
back  to  India  with  the  disabled  liver,  they  are  quickly  ill 
aofain.  This  is  well  seen  in  cases  where  liver-abscess  has 
existed,  and  been  survived.  It  is  those  individuals  with 
the  maimed  liver  of  abnormally  low  functional  activity, 
who  must  be  so  watchful  about  their  dietary,  so  scrupulous 
to  avoid  any  indulgence  approaching  excess.  They  must 
never  forget  what  H.  Nasse  found,"  a  great  increase  of  the 
secretion  of  bile,  when,  with  fat,  nitrogenous  foods  were 
also  given." 

It  is  "  high  tea,"  as  well  as  dinners  and  suppers,  which 
upset  these  beings  w4th  the  congenitally  incapable,  or  with 
maimed  livers.  Tea,  with  cream  and  sugar,  tongue  or 
potted  meat  with  bread  and  butter,  or  buttered  toast,  or 
muffins;  then  these  last  with  jam  or  marmalade,  followed 
by  cheese-cakes,  jam-puffs,  and  a  good  slice  of  pound-cake, 
or  plum  cake  to  finish  up  with:  this  is  the  sort  of  meal 
to  properly  upset  a  child  whose  liver  is  not  at  all  what  it 
might  be.  Such  a  "  feed "  is  well  enough  for  healthy 
children,  with  an  appetite  of  a  polar  bear,  and  the  digestion 
of  an  ostrich;  but  for  the  bilious  child,  or  adult,  it  is  an 
instance  that  "  one  man's  meat  is  another  man's  poison." 
After  this  "party-tea"  the  child  goes  home  to  bed,  and 
awakens  sick  and  feverish.  It  vomits  freely,  and  gets 
relief.  Or  it  is  not  so  quickly  relieved.  It  is  in  high 
fever,  105°  or  so  in  an  hour  or  two;  a  cold  is  suspected, 
not  a  "  surfeit,"  and  it  goes  on  until  it  vomits  a  quantity 
of  pure  bile,  usually  followed  by  purging;  and  then  it  gets 
relief.     Or  an  emetic,  accompanied  by  a  purgative  (some 


CHAP.  X.]  LIVER  DISTURBANCE.  177 

calomel  and  ipecacuan  is  the  common  compound)  is  given, 
and  these  processes  instituted  artificially,  with  the  effect  of 
procuring  relief  and  a  fall  of  the  temperature.  At  other 
times,  more  usually  in  adults,  the  attack  is  less  acute. 
There  is  headache,  a  foul  tongue,  with  a  bitter  taste  in 
the  mouth,  a  vitiated  state  of  the  stools,  and  a  loss  of  all 
appetite.  Here  the  last,  by  leading  to  the  rejection  of  all 
food,  permits  of  the  system  recovering  itself.  The  surplus 
of  albuminoid  material  is  burnt  up  by  oxidation  into  urea; 
and  so  the  system  clears  itself  by  this  starvation.  It  is 
Dame  Nature's  plan  of  striking  a  new  equilibrium  !  And, 
as  such,  ought  to  be  treated  with  respect,  and  not  with 
recipes  to  restore  the  appetite;  which,  if  successful,  would 
only  further  embarrass  the  organism. 

Now  it  is  the  prevention,  rather  than  the  treatment  of 
such  cases  that  calls  for  our  attention.  The  avoidance  of 
the  surfeit  is  too  palpably  called  for,  to  need  a  word  about 
it.  But  it  is  the  fallacy  as  to  the  precise  causation  of  the 
excess  of  bile,  which  renders  it  necessary  to  lay  stress  upon 
the  form  of  food  which  produces  bile.  So  long  as  the  fat 
and  the  sugar  are  held  to  blame,  so  long  will  the  child 
be  erroneously  fed.  It  will  be  allowed  albuminoids,  and 
be  restricted  in  the  matter  of  hydrocarbons  ;  and  so  the 
tendency  to  be  bilious  will  be  directly  fostered.  Adult  or 
child,  the  ordinary  dietary  is  a  little  lean  meat,  dry  bread, 
and  tea,  or  coffee  without  sugar  or  cream.  You  wdll  be 
told,  milk  is  "bilious,"  eggs  are  "bilious,"  butter  is 
"  bilious,"  porridge  is  distasteful !  Yes,  this  is  a  story  with 
which  one  has  long  been  familiar  ;  is  familiar  at  the 
present  time,  and  likely  to  be  "acquainted"  with  for  some 


178  LIVER  DISTURBANCE.  [chat.  x. 

time  to  come — probably  the  rest  of  one's  life-time;  as  I  do 
not  belong  to  a  family  of  centenarians,  but  only  of  fair 
longevity.  The  proper  dietary  is  thus  studiously  avoided, 
and  the  evil  perpetuated. 

What  is  the  appropriate  treatment  dietetic  and  medicinal 
of  this  state  of  affairs  ?  Dietetically  it  is  the  avoidance  of 
albuminoids  (see  p.  137)  in  all  forms,  in  any  quantity.  The 
food  should  consist  of  farinaceous  matters,  fruit  natural 
or  stewed,  vegetables,  fish,  or  a  little  white  meat.  Butter, 
cream,  oil,  or  fat  are  not  forbidden  ;  if  and  provided  nitro- 
genous material  be  not  taken  too  freely  therewith.  Medici- 
nally, an  hepatic  stimulant  of  some  kind,  in  a  dinner-pill, 
or  at  bedtime  with  a  vesretable  laxative  ;  and  next  mornins^ 
a  saline  purgative.  Many  a  chimney  does  not  draw  proper- 
ly because  the  flues  are  not  well  swept.  So  it  is  with  the 
bilious;  it  is  necessary  "to  sweep  the  flues,"  i.e.,  to  keep 
the  bowels  open.  When  this  is  done  certain  desirable  foods 
are  no  longer  found  to  be  "  bilious."  They  agree,  instead 
of  disagreeing  as  before.  Exercise,  plenty  of  exercise  to 
increase  the  oxidysing  processes,  is  most  desirable.  By 
the  union  of  these  measures  the  "bilious"  individual  is 
usually  much  benefited.  But  infinite  care  is  required, 
incessantly  and  unintermittingly.  Occasional  lapses  upset 
the  individual  for  some  time  afterwards.  The  congenitally 
inefficient  liver  is  only  equal  to  the  most  moderate  demands 
upon  it  ;  consequently  it  must  be  compromised  with.  It  is 
a  case  of  Mahomet  and  the  Mountain;  it  would  not  come 
to  him,  so  he  had  to  go  to  it  !  So  the  liver  not  being 
equal  to  what  an  ordinary  normal  liver  can  do,  it  becomes 
necessary  to  reduce  the  food  taken  to  what  it  can  dispose 


C3HAP.  X.]  LIVER  DISTURBANCE.  179 

of.  There  is  no  alternative.  There  is  no  getting  another 
liver:  the  individual  will  have  to  remain  content,  or  dis- 
content as  the  case  may  be,  with  the  viscus  dame  Nature 
has  given  him;  and  he  must  just  accommodate  himself,  or 
lierself,  to  the  inevitable.  It  is  no  doubt  very  hard  that 
such  watchful  care  is  imperatively  necessary,  and  socially 
very  irritating;  but  there  it  is. 

Other  individuals  there  are  who  cannot  take  certain 
wines  without  suffering  for  their  indiscretion.  Some  per- 
sons can  get  through  a  good  dinner  very  fairly  provided 
they  are  not  tempted  to  taste  the  port  wine.  But  if  indis- 
creet enough  "to  try  a  glass  of  port,"  at  the  solicitation  of 
their  host,  next  day  their  liver  resents  the  indiscretion. 
In  others  it  is  champagne  which  alone  must  not  be  touched 
on  any  consideration.  While  with  others  this  is  the  only 
wine  which  they  can  take  without  consequential  suffering. 
"Why  one  wine  alone  should  disagree  with  certain  livers  is 
a  refinement  which  physiology  is  not  3'et  able  to  explain. 
The  alcohol,  the  ethers,  the  salts  are  much  the  same; 
what  is  then  the  minute  matter  which  constitutes  the  dif- 
ference ?  We  must  answer  that  in  the  present  state  of  our 
knowledge,  we  do  not  know.  The  clinical  fact  remaining 
all  the  same  ! 

Now  it  is  time  to  consider  in  some  detail  two  kinds  of 
'•'Liver  Disturbance."  (1)  Biliousness  proper;  (2)  Lithia- 
sis  or  Lithjemia,  which  takes  the  form  of  indigestion, 
rather  than  that  which  is  known  as  gout.  In  the  first,  bile- 
acids  are  the  offending  matter.  In  the  second,  the  forma- 
tion of  lithates  by  the  liver  is  the  malady  par  excellence. 

1.  Biliousness  (proper)  is  the  form  of  hepatic  disturb- 


180  LIVER  DISTURBANCE.  [chap.  x. 

ance  found  in  persons  naturally  "bilious."  Such  persons 
are  ordinarily  dark,  often  swarthy;  but  by  no  •  means 
necessarily  so.  The  typical  bilious  individual  is  dark, 
with  black  hair.  The  skin  is  thick,  wanting  in  trans- 
parency even  if  not  actually  "  muddy,"  there  is  a  large 
development  of  pigment.  The  eyes  are  dark,  the  con- 
junctivae have  a  distinctly  yellow  hue.  When  very  marked 
the  individual  looks  "  steeped "  in  bile;  the  yellow  stain 
showing  itself  everywhere.  The  dark  skin  not  uncom- 
monly presents  a  number  of  freckles  on  the  face.  The 
hands  are  dark,  and  never  white;  indeed  the  hue  is  that 
of  the  lighter-coloured  of  the  dark  races.  Why  there 
should  be  this  development  of  pigment,  the  black  hair, 
the  darkly  pigmented  irides,  it  is  impossible  to  say;  as  we 
do  not  know  the  relations  of  pigment  to  the  colouring 
matters  of  bile.  But  there  is  some  association;  that  is 
clear  enough. 

These  bilious  individuals  may  be  active,  ma}''  be  lethar- 
gic; may  be  circumspect  in  their  living,  or  may  be  care- 
less;  but  they  suffer  for  their  indiscretions  ! 

Their  digestive  canal  is  their  bane  in  life.  Their  appe- 
tite is  capricious;  and  that  is  an  advantage,  as  the  loss  of 
appetite  lessens  the  amount  of  food  taken,  and,  therewith 
the  demand  upon  the  liver.  Their  bowels  are  rarely 
regular;  commonly  they  are  constipated,  ordinarily  with 
diarrhoea  when  the  "  bilious  attack "  is  passing  away. 
They  commonly  have  headache,  and  usually  their  temper 
is  irritable.  They  are  not  as  a  rule  lively  people;  rather 
they  are  gloomy,  or  morose.  The  dark  swarthy  Stuarts 
were  a  bilious  people.     After  reproaching  the  Duke  of 


CHAP.  X.]  LIVER  DISTURBANCE.  181 

Grafton  on  his  descent  from  Charles  the  Second,  Junius 
says — "  There  are  some  hereditary  strokes  of  character,  by 
which  a  family  may  be  as  clearly  distinguished  as  by  the 
blackest  features  of  the  human  face.  Sullen  and  severe 
without  religion,  profligate  without  gaiety  you  live  like 
Charles  the  Second,  without  being  an  amiable  compa- 
nion; and  for  aught  I  know,  may  die  as  his  father  did, 
without  the  reputation  of  a  martyr."  The  swarthy  skin, 
the  peculiar  turn  of  mind,  are  each  a  part  of  the  bilious 
temperament;  alike  the  outcome  of  something  which  is 
causal  to  both.  The  old  Greeks  used  the  word  "  Melan- 
cholia "for  mental  depression;  "  black-bile,"  as  it  means, 
was  they  held  the  physical  cause  of  a  state  of  mental  de- 
pression. When  under  the  influence  of  a  bilious  attack, 
this  mental  attitude  is  aggravated,  and  the  irritability  and 
depression  are  pronounced.  The  character  of  James  the 
Second  is  in  harmony  with  a  persisting  biliousness. 

Now  the  bile-acids  and  the  colouring  matter  of  bile,  are 
not  the  same  thing;  just  as  the  colouring  matter  of  the 
urine  and  the  urine  solids  (proper)  are  not  the  same  thing. 
But  a  high-coloured  urine  is  usually  a  urine  of  high  speci- 
fic gravity.  And  an  icteric  hue  is  usually  found  with  bili- 
ary disturbance.  Both  the  colouring  matters  of  bile  are 
nitroo:enised  matters. 


o 


Bilirubin  C,H,,N,03. 
Biliverdin  C,,H,„N,0,. 

tell  of  their  derivation  from  albuminoid  material  orior-in- 
ally,  if  immediately  the  products  of  the  destruction  of 
haemoglobin.     Glycogen  which  unites  with  cholic  acid  to 


182  LIVER  DISTURBANCE.  [chap.  x. 

form   glycocholic    acid,   has   the    formula    C2H5NO2;    and 
taurin  C,H,N03S. 

The  bile  colouring  matter  and  the  bile  acids  go  together. 
Where  the  one  is,  the  other  is  not  far  away.  Taurocholic 
acid  is  the  material  which  gives  the  bitter  taste  in  the 
mouth  in  biliary  disturbance;  it  does  not  give  the  yellow 
hue  to  the  fur  on  the  tongue,  but  the  two  go  together  clini- 
cally. The  tongue  is  usually  furred,  the  fur  being  yellow 
or  even  brown,  first  thing  in  the  morning;  if  persisting  all 
day,  worst  then.  Along  with  this  is  experienced  a  bitter 
taste  in  the  mouth.  Sometimes  the  tongue  looks  quite 
clean  when  a  bitter  taste  is  complained  of;  but  if  the  pa- 
tient be  placed  in  the  light  and  then  the  eye  is  brought 
near  to  a  level  with  the  tongue,  so  as  to  look  along  it,  then 
the  yellow,  or  brown  hue  is  perceptible,  which  was  unno- 
ticeable  before;  just  as  a  dyer  holds  up  a  skein  of  silk,  side- 
ways to  the  eye,  when  he  wishes  to  be  very  certain  about 
the  shade  of  colour.  Where  there  is  co-existing  old  stand- 
ing debility,  the  tongue  is  swollen,  pale,  flabby,  and  show- 
ing the  indentations  of  the  teeth  at  its  edges,  while  its 
surface  is  whitish,  and  its  j^apillse  are  long.  "  If  the  liver 
be  somewhat  congested,  with  these  appearances  we  may 
often  observe  the  fungiform  papillae  on  the  tip  and  edges 
larger  and  redder  than  natural.  In  other  cases,  and  espe- 
cially when  there  is  at  the  same  time,  more  or  less  gastric 
catarrh,  the  whole  surface  of  the  tongue  is  uniformly  cov- 
ered with  a  thick  fur,  sometimes  whitish,  but  occasion- 
ally of  a  yellowish  or  brownish  tint.  According  to  Sir 
James  Paget,  psoriasis  of  the  tongue,  difficult  to  distin- 
guish from  syphilitic  psoriasis,  occasionally  results  from 


CHAP.  X.]  LIVER  DISTURBANCE.  183 

gout "  (Murchison).  Tlie  tongue  is  worthy  of  careful 
study  and  minute  inspection,  in  all  cases  of  disturbance 
of  the  chylopoietic  viscera. 

Disorder  of  the  bowels  is  common.  There  is  torpor 
often  with  flatulence.  The  bowels  are  irregular;  either 
constipated  always,  or  constipation  alternates  with  loose- 
ness. Often  acidity  is  complained  of  in  the  intestines, 
with  a  headache  of  its  own.  Prout,  in  his  well-known 
work  on  "  Stomach  and  Urinary  Diseases,"  says  of  this 
trouble — "When  acidity  prevails  in  the  lower  portion  of 
the  intestinal  canal,  and  particularly  in  the  coecum,  the 
treatment  must  be  modified  to  meet  the  circumstances. 
The  soluble  antacids  in  this  case  have  comparatively  little 
effect,  from  their  being  neutralized  and  absorbed  before 
they  reach  the  seat  of  the  affection  ;  hence  the  insoluble 
antacids,  and  particulary  magnesia,  will  in  general  be 
found  most  useful  in  such  cases.  The  shortest  mode, 
however,  of  getting  rid  of  the  immediate  inconvenience  of 
acidity  in  the  lower  bowels,  is  usually  to  inject  a  pint  or 
two  of  warm  water  (or  of  soap  and  water),  and  thus  of  re- 
moving the  offending  cause.  By  this  simple  remedy  I  have 
often  seen  the  severe  nervous  headache,  and  other  unplea- 
sant symptoms  usually  accompanying  acidity  in  the  lower 
bowels,  immediately  removed.  Those  who  suffer  from  such 
causes  usually  require  the  aid  of  purgatives,  which  in  gen- 
eral are  better  taken  at  bedtime.  Purgatives  of  a  mild 
but  effectual  kind,  such  as  the  Decoct.  Aloes  Comp.  with 
magnesia  often  suit  well;  as  do  pills  taken  at  a  late  dinner 
if  duly  adjusted  to  the  circumstances  of  the  case.  Drastic 
purgatives  in  general  should  be  avoided;  for  though  they 


184  LIVER  DISTURBANCE.  [chap.  x. 


sometimes  give  immediate  relief,  they  usually  leave  the 
patient  more  inveterately  disposed  to  the  disease.  Neither 
this  class  of  diseases,  nor  the  remedies  adopted  to  remove 
them,  have  been  so  carefully  studied  as  they  deserve  to  be." 
What  Prout  complains  of  in  the  concluding  sentence,  still 
continues  to  hold  good.  Matters  requiring  "  careful  study  " 
never  have  been,  never  will  be,  properly  attended  to,  un- 
less humanity  undergoes  some  prepared  modification  af- 
fecting the  multitude,  and  disposing  it  favorably  to  ear- 
nest thought;  which  will  be  about  the  advent  of  the 
Millennium  ! 

The  stools  are  sometimes  pale,  "  wanting  in  bile,"  we 
say  ;  and  this  is  common  when  there  is  a  deposit  of 
lithates  in  the  urine.  Commonly  they  possess  a  very 
offensive  odor.  At  other  times  the  stools  are  pale  and 
putty-like,  while  the  urine  possesses  a  very  offensive  odor 
immediately  when  passed.  This  condition  I  have  met 
with  in  elderly  women  with  ansemia  and  large  livers;  it 
is  common  to  hear  them  complain  of  the  offensive  charac- 
ter of  their  urine;  ''I  can't  abide  myself,"  is  a  frequent 
expression  with  them.  It  would  seem  that  there  is  present 
in  the  urine  some  substance  possessing  the  properties,  to 
the  nose  at  least,  of  skatol  or  indol.  Certain  it  is  there  is 
some  perversion  of  assimilation,  or  metabolism,  or  oxidation 
which  shows  how  closely  the  liver  and  the  urine  are  linked 
together.  At  other  times  they  are  lumpy,  dark  coloured, 
and  offensive,  as  if  too  long  in  contact  with  the  intestinal 
secretions.  Such  stools  often  alternate  with  diarrhoea, 
when  the  stools  are  charged  with  bile  producing  the  sen- 
sation of  scalding  at  the  vent,  as  if  the  motion  consisted 


CHAP.  X.]  LIVER  DISTURBANCE.  185 

of  "red-hot  sand; "  leaving  behind  it  a  good  deal  of  irrita- 
tion. Chronic  conditions  of  anal  itching  are  always  the 
concomitant  of  biliary  disturbance  in  persisting  indigestion. 
These  stools,  black  and  offensive,  have  a  term  for  them, 
viz.,  "  vitiated,"  an  expressive,  old-fashioned  phrase.  The 
urine  is  usually  high-colored,  but  clear  ;  at  other  times  it 
contains  a  deposit,  which  may  vary — may  be  white,  fawn- 
colored,  or  "brick-dust  "  in  hue.  Indeed,  the  whole  phe- 
nomena are  those  of  excess  of  bile,  poisoning  the  Avhole 
system,  and  chiefly  disturbing  the  digestive  canal.  The 
bile-acids  here  are  the  disturbing  agents,  in  all  probability 
at  least. 

The  following  is  Murchison's  summary. — "  The  symp- 
toms, usually  associated  with  a  deficient  excretion  of  bile, 
are  an  irregular,  usually  costive  state  of  the  bowels,  the 
stools  being  insufficiently  colored  with  bile,  and  of  a  pale 
yellow,  drab,  or  whitish  color  ;  loss  of  appetite,  a  white  or 
yellowish  tongue  ;  a  disagreeable,  often  bitter  taste  in  the 
mouth,  especially  in  the  morning  ;  flatulence  ;  a  yellow  or 
muddy  tint  of  skin  (indicating,  unless  there  be  concurrent 
hyper£emia  of  the  liver,  ansemia  rather  than  jaundice)  ; 
dingy  conjunctivae;  languor  and  disinclination  for  exertion; 
frontal  headache  ;  dulness  and  heaviness,  drowsiness  after 
meals  ;  great  depression  of  spirits,  and  sometimes  hypo- 
chondriasis ;  and  frequent  deposit  of  lithates  in  the  urine 
on  cooling.  These  symptoms  are  very  apt  to  be  induced, 
especially  toward  middle  life,  by  sedentary  and  indolent 
habits,  the  habitual  use  of  rich  or  indierestible  food,  neo-lect 
of  the  bowels,  great,  or  protracted  anxiety  of  mind,  or  by 
a  general  want  of  vigor,  consequent  upon  disease  of  the 


186  LIVER  DISTURBANCE.  [chap.  x. 


heart  or  of  some  other  organ  ;  and  the  tendency  to  them 
is,  in  many  cases,  inherited.  They  are  commonly,  and 
perhaps  correctly,  ascribed  to  what  is  called  "  torpidity  of 
the  liver,"  but  the  non-excretion  of  bile  may  possibly  be 
merely  one  of  the  symptoms,  rather  than  the  cause  of  the 
morbid  state;  the  real  cause  being  the  retention  in  the  sys- 
tem, not  of  bile,  but  of  those  products  of  disintegration 
which  it  is  the  purpose  of  the  kidneys  to  eliminate.  At  the 
same  time,  it  is  very  probable  that  engorgement  of  the 
liver  with  bile  interferes  with  the  normal  processes  of  dis- 
integration of  albumen  which  takes  place  in  the  gland." 
And  it  certainly  is  probable  that  there  is  a  surplusage  of 
bile  in  these  cases.  Useful  in  normal  amount  in  the  assi- 
milation of  fat,  freely  poured  out  and  freely  absorbed  more 
than  once,  a  large  quantity  of  bile  may  be  accumulated, 
that  portion  normally  cast  out  by  the  bowels  being  reab- 
sorbed ;  why,  we  cannot  tell  in  the  present  state  of  our 
knowledge,  the  clinical  fact  remaining  all  the  same.  The 
purgatives  which  are  operative  in  such  cases  are  those 
which  act  upon  the  upper  part  of  the  intestine,  and  sweep 
away  a  quantity  of  bile  too  swiftly  for  its  absorption  by  the 
bowel  lower  down.  Such  are  notably  mercury,  rhubarb, 
aloes  (as  well  as  acting  on  the  colon),  and  podophyllin,  or 
gamboge.  The  utter  inability  of  purgatives  like  s,ulphate 
of  magnesia  and  castor  oil  to  relieve  conditions  of  bilious- 
ness is  well  known.  The  patient  with  the  furred  tongue, 
bad  taste  in  the  mouth,  and  general  languor  and  malaise, 
states  that  the  bowels  have  been  freely  opened  by  these 
agents;  yet  no  sense  of  relief  is  experienced  therefrom.  A 
laxative  containing  mercury  brings  away  some  bile-laden 


CHAP.  X.]  LIVER  BI8TURBANGE.  187 

stools,  and  the  sense  of  relief  is  marked;  while  the  tongue 
cleans,  and  the  bitter  taste  in  the  mouth  disappears.  Such 
a  remedial  agent  a  by-past  generation  called  an  "  altera- 
tive," a  term  justified  by  the  clinical  facts;  but  not  to  be 
explained  satisfactorily  otherwise  in  the  present  state  of 
our  knowledge.  ^Yhen  the  surplusage  of  bile  is  swept 
away,  the  system  feels  relieved,  the  appetite  returns,  and 
assimilation  is  restored.  It  is  clear  from  this  that  a  certain 
amount  of  bile  only  is  required  for  the  purposes  of  diges- 
tion, and  the  overplus  can  truly  be  regarded  as  excremen- 
titious.  In  this  matter  we  must  still  look  to  the  utterances 
of  clinical  medicine,  as  physiology,  just  yet,  is  not  in  the 
position  to  speak  authoritatively.  Probablj'',  ere  many 
years  have  passed  away,  it  will  have  much  to  tell  us  that 
we  will  be  very  glad  to  hear;  as  in  the  past  so  probably  in 
the  future,  our  clinical  observations  will  be  corroborated  as 
well  as  explained  by  advancing  physiological  knowledge. 
At  least  there  is  every  reason  to  believe  so  from  the  lessons 
of  the  past. 

In  the  meantime  it  is  not  unwarrantable,  nor  yet  out  of 
place,  to  throw  together  a  few  matters  which  will  at  least 
be  suggestive  in  the  aggregate;  if  nothing  more  can  be 
claimed  for  them..  Ti\p  bile  is  a  fluid  which  passes  very 
easily  through  animal  membranes;  not  only  that,  but 
when  such  membranes  are  wetted  with  bile,  oil  easily 
passes  through  them.  It  is  easy  then  to  comprehend 
how  bile  may  very  readily  escape  out  of  the  bowels  into 
the  portal  venules,  if  allowed  to  remain  in  contact  w^ith 
the  bowel.  It  is  secreted  under  a  very  low  pressure,  a  fact, 
the  importance  of  which  we  scarcely  are  yet  in  a  position 


188  LIVER  mSTURBANGE.  [chap.  x. 

to  fully  realise.  It  is  a  fluid  evidently  which  is  freely 
poured  out  and  readily  absorbed,  and  may  circulate  in  the 
chylopoietic  viscera  in  abnormal  quantities  some  time,  be- 
fore being  cast  out  of  the  system  by  the  act  of  spontaneous 
purgation;  sometimes  accompanied  by  vomiting. 

When  such  an  accumulation  of  bile  exists,  sooner  or 
later  the  natural  eliminating  action  comes  into  play,  giv- 
ing relief.  The  diarrhoea,  of  which  the  patient  complains, 
and  asks  for  a  remedy,  is  the  natural  means  of  restoring 
an  equilibrium  once  more.  It  is  the  thunderstorm  which 
clears  the  air  :  and  therefore  the  patient  should  be  grateful 
for  it.  But  it  is  not  in  humanity,  in  its  sublunary  state 
anyhow,  to  be  grateful  for  what  is  unpleasant. 

Now  a  very  interesting  question  suggests  itself,  but  does 
not  bring  with  it  a  complete  or  satisfactory  answer  ;  and 
it  is  this.  Is  it  the  excess  of  bile-acids  which  produces  the 
lethargy,  the  depression,  the  "  melancholy,"  of  the  bilious 
attack;  or  is  it  that  in  a  bile-laden  state  the  liver  is  im- 
paired in  its  filtering  power,  and  allows  peptones,  or  other 
crude  matters  of  gastro-intestinal  digestion,  to  pass  through 
it  into  the  general  current  of  the  blood  ? 

The  question  is  one  which  at  least  is  worthy  of  con- 
sideration, even  if  a  positive  answer  cannot  be  given  to 
it.  Such  consideration  will  enlarge  our  acquaintance  with 
the  subject;  and  that  is  good,  even  if  but  imperfect  good. 
One  part  of  the  subject  is  clear  enough  anyhow,  and  it  is 
this.  The  normal  products  of  digestion  give  us  agreeable 
sensations,  a  part  of  which  is  a  sense  of  energy.  But  this 
varies.  A  small  meal  is  more  apt  to  give  the  sense  of 
energy  and   well-being;  while  a  full  meal  gives  a  very 


CHAP.  X.]  LIVER  DISTURBANCE,  189 

pleasant  sense  of  well-being  combined  with  a  feeling  of 
dolce  far  niente,  of  disinclination  to  exertion.  But  that 
the  mental  associations  of  normal  digestion  are  pleasant, 
there  can  bo  no  doubt.  Charity  dinners  demonstrate  the 
belief  in  the  effects  of  a  good  meal  ujDon  the  generous  im- 
pulses. Young  ladies  talk  to  their  papas  after  dinner 
about  their  lovers,  when  they  know  that  some  objections 
exist  to  them  in  the  paternal  mind.  Mamas  know  this 
too.  "A  hungry  man  is  an  angry  man;"  when  a  man's 
stomach  is  full  he  is  inclined  to  be  amiable.  That  is  a 
well  recognised  fact.  But  when  the  products  of  digestion 
are  abnormal,  then  a  very  different  mental  state  is  pro- 
duced. There  is  depression,  with  irritability;  no  matter 
whether  the  state  is  one  of  ordinary  "biliousness,"  or  one 
of  "lithasmia."  Whether  lithates  or  bile-salts  are  the  of- 
fending matter,  the  mental  state  is  not  one  of  well-being-, 
but  the  opposite.  Nor  is  it  the  posterior  sensory  lobes  of 
the  hemispheres  alone  which  are  involved.  We  know  that 
Cyon  and  Aladoff  have  traced  a  direct  nervous  communica- 
tion betwixt  the  liver  and  the  posterior  lobes  of  the  brain, 
that  portion  of  the  cerebrum,  indeed,  which  is  linked  with 
our  subjective  sensations.  There  is  this  matter  of  nerve- 
communication  by  fibres  of  the  sympathetic  to  be  borne  in 
mind;  this  '' sympath}^,"  as  well  as  the  direct  effect  upon 
the  sensorium  of  the  abnormal  matters — abnormal  in  cha- 
racter or  in  amount,  circulating  in  the  blood.  Such 
poisoned  blood,  too,  produces  modifications  of  sensation. 

There  is  the  general  cutaneous  itching  of  jaundice,  well- 
recognised;  and  the  itching  of  lithiasis,  the  general  pru- 
rigo  of  inefficient  renal  action,  seen   in  the  subjects  of 


190  LIVER  DISTURBAN'GE.  [chap.  x. 

chronic  Bright's  disease.  There  are  burning'  or  scalding 
patches,  and  sometimes  "  lightning  flashes  "  of  acute  pain, 
and  hyperresthesia  in  those  who  are  the  subjects  of  lithia- 
sis;  as  sudden  sometimes  as  the  pains  of  locomotor  ataxy. 
There  is  neuralgia.  Also  severe  cramps.  While  head- 
ache is  almost  invariably  present.  It  may  be  "  megrim," 
or  it  may  be  "  frontal,"  through  both  temples ;  or  it 
may  be  "  vertical,"  or  "  occipital,"  or  even  it  may  be 
general.  Usually  it  is  accompanied  by  a  sense  of  nausea 
and  ana3mici. 

Alterations  of  vision,  dimness  of  sight,  etc.,  or  modifi- 
cations of  hearing-,  sounds  in  the  ears,  buzzing,  or  ringing, 
may  be  experienced.  One  eye  may  be  more  affected  than 
the  other,  or  one  ear;  or  there  may  be  vertigo,  or  a  sense 
of  dizziness,  or  swimming  experienced.  Even  convulsions 
are  not  unknovv^n  as  the  result  of  such  toxaemia. 

More  striking  still  is  the  cardiac  disturbance  set  up  by 
this  poisoning  by  bile  in  the  blood.  Bile  has  been  found 
experimentally  to  have  "  a  direct  paralysing  action  on 
muscles"  by  Ranke;  and  Wickham  Legg  agrees  with  him 
as  to  the  action.  Rohrig  first  clearly  showed  that  it  is 
the  bile-acids,  and  not  the  bile-pigment  or  cholesterin, 
which  causes  the  slow  pulse.  At  other  times,  there  is  a 
lowering  of  the  blood-pressure,  with  that  rapidity  of  the 
pulse  which  is  linked  therewith;  and  this  slow  pulse,  or 
rapid  pulse  depends  upon  the  condition  of  the  sympathetic 
system,  according  to  Traube.  It  appears,  too,  that  bile- 
acids  in  any  quantity  in  the  blood  are  destructive  to  the 
red  corpuscles. 

There  is  then  another  factor  in  the  depression  produced 


CHAP.  X.]  LIVEE  DISTURBANCE.  101 

beyond  that  (1)  of  the  direct  action  of  the  bile-laden  blood 
upon  the  brain;  and  (2)  the  sympathy  bet\A'ixt  the  liver 
and  the  posterior  lobes,  by  their  direct  nerve-communica- 
tion; there  is  (3)  the  elfect  upon  the  circulation,  lowering 
the  blood-pressure  in  the  brain  as  well  as  elsewhere.  No 
wonder  then  that  there  is  depression  linked  with  irrita- 
bility: the  depression  of  brain  actually  ill-fed,  with  the 
irritability  caused  by  the  positive  presence  of  a  blood- 
poison.  "  The  influence  of  the  liver  upon  the  animal 
spirits  has  been  recognized  by  medical  writers  in  all  ages. 
To  the  belief  in  the  existence  of  such  an  influence  may  be 
traced  the  origin  of  such  terms  as  llypocliondriasis  and 
ATelancholia.  Although  it  is  not  contended  that  the  morbid 
states  of  mind,  to  which  at  the  present  day  we  apply  these 
terms,  have  their  origin  in  the  liver,  they  are  unquestion- 
ably, in  many  instances,  accompanied  and  aggravated  by 
derangement  of  the  organ;  and  it  is  equally  true  that, 
independently  of  either  hypochondriasis  or  melancholia, 
persons  with  functional  derangement  or  structural  disease 
of  the  liver  are  subject  to  fits  of  great  depression  of  spirits, 
and  often  groundless  fears  of  impending  danger,  which 
cease  when  the  liver  is  restored  to  its  normal  state. 
Irritability  of  temper  is  another  common  symptom  of  func- 
tional derang-ement  of  the  liver,  and  is  sometimes  the  first 
indication  of  anything  wrong.  A  man  who  has  previously 
borne  the  crosses  of  life  with  equanimity,  and  been  amiable 
to  those  about  him,  gradually  becomes  disconcerted  by 
trifles;  his  mind  broods  upon  them;  and  he  makes  all 
around  him  unhappy,  and  himself  the  most  miserable  of 
all.  His  relatives  perceiving  no  other  sign  of  indisposition, 


192  LIVER  DISTURBANCE.  [chap.  x. 

and  failing  to  recognize  the  true  cause,  too  often  put  down 
the  ebullitions  of  temper  to  something  mentally  or  morally 
wrong;  to  moral  depravity,  or  failure  to  make  any  mental 
effort,  but  remedial  measures  calculated  to  restore  the  liver 
to  healthy  action,  if  resorted  to  in  time,  will  often  remove 
the  irritability,  and  either  the  patient's  improvement  under 
such  treatment,  or  an  attack  of  gout,  reveals  the  cause  of 
the  patient's  bad  temper."  So  writes  Dr.  Murchison. 
And  there  is  no  doubt  much  of  what  Americans  call  "  pure 
cursedness"  is  due  to  a  toxsemic  state  of  the  blood,  con- 
taining as  it  does  "  bile-poison."  The  subjective  sensations 
of  the  individual  are  unenviable,  to  put  it  as  mildly  as 
possible.  I  remember  a  lady  of  very  fine  sentiments  and 
strong  religious  feeling,  who  became  quite  alarmed  at  what 
she  regarded  as  her  own  perversity  and  innate  wickedness, 
and  the  inefficacy  of  prayer — who  recovered  her  normal 
state  of  mind  on  a  line  of  treatment  which  filled  her  brain 
with  healthy  blood.  In  some  cases  the  second  factor — the 
direct  sympathy  betwixt  the  liver  and  the  posterior  lobes 
of  the  brain,  exercises  a  distinct  influence;  and  the  sensory 
portion  of  the  brain  is  more  affected  than  the  rest  of  it,  i.e., 
the  posterior  portion  supplied  by  the  vertebral  arteries  * 
which  is  related  to  tlie  subjective  sensations,  is  more  af- 
fected than  the  intellectual  or  motor  areas.  Consequently 
we  find  a  peculiar  state  of  mind.  There  is  perverted 
emotion  wdth  a  distinct  perception  of  the  perversion.  Thus 
Jean  Jacques  Rousseau  wrote — "I  feel  bitterly  my  wrong 

*  Not  only  is  the  blood-supply  special,  but  the  sympathetic  nerve- 
supply  to  the  vertebral  arteries  is  derived  from  the  lower  cervical  ganglia ; 
that  of  the  internal  carotids  from  the  superior  cervical  ganglia. 


CHAT.  X.]  LIVER  DISTUEBAN-CE.  193 

conduct  and  tlie  baseness  of  my  suspicions;  but  if  any- 
thing can  excuse  mc  it  is  rny  mournful  state,  my  loneli- 
ness.'' The  intellect  here  was  perfectly  conscious  that 
there  was  a  morbid  condition  of  the  emotions  which  it  was 
evidently  unable  to  control.  The  late  Thomas  Carlyle 
knew  what  this  horrible  feeling  was — "The  accursed  hag 
dyspepsia  had  got  me  bitted  and  bridled,  and  was  ever 
striving  to  make  my  living-day  a  thing  of  ghastly  night- 
mares; I  resisted  what  I  could,  never  did  yield  or  surrender 
to  her;  but  she  kept  my  heart  right  heavy,  my  battle  being 
sore  and  hopeless."  Yet  he  strove  on  under  the  infliction; 
his  experience  fully  bearing  out  what  is  written  in  the  in- 
itial sentence  of  this  book.  There  is  little  real  difference  be- 
twixt the  action  of  bile-acids  or  lithates  in  their  toxic  effect 
upon  the  brain-cells.  Both  act  potently.  It  is  scarcely, 
however,  a  complete  consideration  of  the  subject  to  leave 
it  here.  To  revert  to  Dr.  Brunton's  paper,  it  would  seem 
tliat  there  are  gases  evolved  in  certain  states  of  disorder  of 
the  assimilative  organs  which  are  distinctly  toxic  in  their 
effects.  He  follows  Dumarquay  as  to  the  absorption  of 
sulphuretted  hydrogen  from  the  intestine.  "In  cases  of 
indigestion  this  gas  seems  to  be  not  unfrequently  found, 
because  persons  often  complain  of  the  taste  of  rotten  eggs 
in  the  mouth,  or  in  the  eructations.  Even  in  such  small 
quantities  it  is  not  improbable  that  it  may  exert  a  deleteri- 
ous influence  both  upon  the  nervous  system,  and  upon  the 
blood,  for  it  is  a  powerful  poison,  in  its  action  somewhat 
resembling  hydrocyanic  acid,  though  not  so  strong."  In 
some  cases  the  production  of  sulphuretted  liydrogen  may 
be  a  factor  in  the  nervous  depression  produced. 


19J:  LIVER  DISTURBANCE.  [chap.  x. 

He  writes  : — "The  greatest  care  appears  to  have  been 
taken  in  the  construction  of  the  liver  to  prevent  the  bile 
from  coming  in  contact  with  the  blood  ;  the  ultimate 
radicles  of  the  bile-ducts  or  biliary  capillaries  being  placed 
as  far  from  the  blood  capillaries  as  the  structure  of  the 
liver  will  allow.  Notwithstanding  this  care,  the  distance 
between  the  blood  and  the  bile  capillaries  is  small,  though 
it  is  sufficient  under  ordinary  circumstances  to  prevent  the 
absorption  of  bile  into  the  blood.  But,  whenever  an  ob^ 
struction  takes  place  to  the  exit  of  bile,  and  the  pressure 
of  bile  in  the  biliary  capillaries  increases,  an  absorption  of 
this  secretion  occurs.  Bile  is  secreted  under  a  very  low 
pressure,  and  a  very  slight  increase  in  this  is  sufficient  to 
cause  reabsorption." 

He  goes  on: — "  But  bile  is  not  the  only  substance  which 
produces  a  depressing  effect  upon  the  circulation,  when 
absorbed  into  it  from  the  portal  circulation.  In  many 
cases  of  nervous  depression  we  find  a  feeling  of  weakness 
and  prostration  coming  on  during  digestion,  and  becoming 
so  very  marked  about  the  second  hour  after  a  meal  has 
been  taken,  and  at  the  very  time  when  absorption  is  going 
on,  that  we  can  hardly  do  otherwise  than  ascribe  it  to 
actual  poisoning  by  digestive  products  absorbed  into  the 
circulation.  From  the  observation  of  a  number  of  cases 
I  came  to  the  conclusion  that  the  languor  and  faintness  of 
which  many  patients  complained,  and  which  occurred 
about  eleven  and  four  o'clock,  was  due  to  actual  poisoning 
by  the  products  of  digestion  of  breakfast  and  lunch;  but 
at  the  time  when  I  arrived  at  this  conclusion  I  had  no 
experimental  data  to  show  that  the  products  of  digestion 


CHAP.  X.]  LIVER  DISTURBANCE,  195 

were  actually  poisonous  in  themselves,  and  only  within  the 
last  few  months  have  I  seen  the  conclusions,  to  which  I 
had  arrived  by  clinical  observations,  confirmed  by  experi- 
ments made  in  the  laboratory.  Such  experiments  have 
been  made  by  Professor  Albertoni  of  Genoa,  and  by  Dr. 
Schmidt-Miihlheim,  in  Professor  Ludwig's  laboratory  at 
Leipsic."  (What  these  observations  were  is  given  at 
p.  164).  We  thus  see  that  there  are  many  factors  in  the 
production  of  the  nervous  depression,  and  disturbance 
linked  with  abnormal  action  in  the  liver.  If  the  nervous 
system  strongly  affects  the  liver  when  perturbed  (Chap,  ix.), 
it  is  also  abundantly  clear  that  the  liver  when  disordered, 
produces  a  potent  effect  upon  the  cerebral  hemispheres. 
These  two  halves  of  the  subject  are  well  worth  keeping  in 
mind  and  contrasting. 

So  much  for  the  consideration  of  the  nervous  phenomena 
provoked,  or  set  up  by  disturbance  of  the  function  of  the 
liver. 

We  may  now  consider  the  effect  of  the  bile-laden  blood 
upon  the  heart.  In  using  here  the  term  "^bile-laden,"  it 
is  intended  it  shall  embrace  these  other  products  which 
may  co-operate  with  the  bile  in  producing  nerve-disturb- 
ances. We  saw  at  p.  190  that  bile  is  a  poison  acting  upon 
the  heart.  We  saw  further  that  its  action  was  not  alike 
in  all  cases;  and  that  Traube  held  this  difference  to  be  due 
to  the  condition  of  the  sympathetic  system.  What  actually 
occurs  in  practice  bears  out  the  views,  of  Traube.  At 
times  patients  present  themselves  with  deep  depression  of 
the  nervous  sj^stem,  while  the  heart's  action  is  slow  and 
feeble.     Here  there  is  direct  action  upon  the  cardiac  ven- 


196  LIVER  DISTURBANCE.  [chap.  x. 

tricles  through  the  inhibitory  fibres  of  the  vagus.  The 
depressing  effect  of  the  bile-laden  blood  upon  the  cerebral 
hemispheres  is  intensified  by  the  comparative  anaemia  of 
the  brain,  consequent  upon  the  arrested  action  of  the 
heart.  The  defective  blood-supply  produces  the  symptoms 
of  cerebral  anaemia,  and  blends  them  with  those  of  biliary 
toxaemia.  The  pulse  is  slow,  frequently  unequal,  corre- 
sponding to  the  stroke  of  the  ventricle.  This  irregular 
action  of  the  heart  alarms  the  patient,  already  depressed 
by  the  effects  of  the  bile  upon  the  brain,  and  causes  the 
impression  of  "something  wrong  with  the  heart''  to  take 
possession  of  the  patient's  imagination,  and  to  cause  him, 
or  her  much  needless  alarm.  But  it  is  not  easy  to  con- 
vince them  that  the  alarm  is  needless,  and  without  real 
foundation.  Impressions  founded  on  subjective  sensations 
aie  not  easily  laid  at  rest;  they  raise  their  hydra-headed 
front  again  and  again,  in  spite  of  all  the  efforts  made  to 
keep  them  in  subjection.  The  horrible  sensations  and  the 
irregular  action  of  the  heart  will  range  themselves  together 
in  a  most  suggestive  manner.  Just  as  the  Hydra  grew 
another  head  as  fast  as  one  was  cut  off,  so  the  disordered 
imagination  will  yield  to  the  suggestive  associated  facts, 
and  put  its  own  interpretation  on  the  linked  phenomena. 
Assure  them  that  there  is  no  actual  disease  of  the  heart, 
they  depart  comforted;  for  the  time.  But  in  a  little  while 
the  impression  comes  back,  with  a  rebound  as  it  were* 
and  the  apprehensions  of  organic  disease  are  as  dominant 
and  dominating  as  ever.  Yet  when  the  function  of  tlie 
liver  is  restored,  and  the  blood  is  once  more  freed  from 
bile,  and  its  kith  and  kin,  the  mind  escapes  from  the  in- 


CHAP.  X.]  LIVER  BISTURBANCE.  197 

cubus  which  bestrode  it;  and  tlie  reason  once  more  re- 
sumes its  wonted  sway.  The  condition  passes  away;  like 
a  bad  dream  leaving  behind  it  for  a  time  a  painful  feeling; 
which  haunts  the  sufferer  like  the  refrain  of  mournful 
Music — a  melancholy  symphony  ! 

At  other  times,  the  symptoms  are  those  of  a  low  blood- 
pressure,  with  a  rapid  pulse.  Here  there  is  palpitation  at 
times;  often  severe,  and  alarming  the  patient.  It  is  well 
known  that  with  a  low  blood-pressure  in  the  arteries  the 
heart's  action  is  rapid.  The  roots  of  the  vagus,  are  not 
freely  supplied  with  blood,  and  then  the  accelerator  fibres 
of  "that  rope  of  varied  strands,"  the  vagus  are  thrown 
into  action.  At  times  this  leads  to  positive  palpitation, 
the  contractions  of  the  ventricle  being  so  quick  and  vigor- 
ous. It  is  indeed  a  true  form  of  neurosal  palpitation,  not 
influenced  by  effort.  It  also  disappears  when  the  func- 
tional activity  of  the  liver  is  regained  under  appropriate 
measures:  the  first  step  being  to  get  rid  of  superfluous 
bile-products,  and  other  albuminoid  matters,  and  to  so  feed 
the  patient  as  to  give  the  liver  but  little  to  do.  A  dietary 
containino-  little  albuminoids  is  the  one  most  suitable  as 
taxing-  the  liver  little  in  the  metabolism  of  nitrogenised 
matters. 

Sleeplessness  is  another  symptom  much  complained  of 
by  these  bilious  patients,  and  it  is  linked  with  the  cardiac 
disturbances  very  closely.  The  patient  complains  of  in- 
ability to  sleep,  in  vain  it  is  courted  for  hours;  it  will  not 
be  wooed.  The  sleepless  hours  are  in  themselves  barely 
tolerable;  but  when  in  addition  to  this,  the  disturbed  car- 
diac action  is  present,  the  condition  becomes  almost  un- 


198  LIVER  DISTURBANCE.  [chap.  x. 

bearable.  The  sleejDless  patient  feels  at  times  as  if  the 
heart  really  would  stop,  its  pulsations  become  so  slow  and 
feeble.  Dej^ressed  before,  this  deepens  the  gloom;  and  a 
sense  of  misery  is  intensified  by  apprehensions  of  approach- 
ing dissolution.  When  there  is  palpitation,  the  case  is 
different.  In  the  silent  watches  of  the  night,  the  sufferer 
is  suddenly  wakened  out  of  sleep  by  a  violent  paroxysm  of 
palpitation.  This  is  alarming  enough;  but  when  the  vio- 
lent beats  are  succeeded  by  apparent  sudden  stoppage, 
then  the  dread  indeed  is  acute.  So  long-  as  the  heart  is 
violently  beating,  the  sufferer  is  comparatively  easy  in 
mind;  but  when  the  sense  of  stoppage  comes,  then  the 
sensation  is  that  of  dying.  The  evil  effects  of  this  are  not 
immediate  only,  the  shock  upsets  the  patient  for  some  time 
afterwards,  and  is  only  slowly,  and  not  rarely  imperfectly 
recovered  from.  Dr.  Murchison  writes — "  Sleeplessness 
may,  of  course,  arise  from  many  different  causes,  but  one 
of  its  causes  is  that  derangement  of  the  liver,  which  pro- 
duces lithsemia.  When  this  is  the  case,  the  patient  is 
often  heavy  and  drowsy  after  a  full  meal,  and  he  may  fall 
asleep  at  once  on  retiring  to  rest;  but  after  one,  two, 
three,  or  four  hours,  he  awakes,  and  then  he  either  lies 
awake  for  hours,  or  he  is  constantly  falling  asleep,  dream- 
ing, or  having  the  nightmare,  and  awaking — four  or  five 
times,  or  even  oftener  in  the  course  of  one  hour — until  the 
morning  comes,  when  he  drops  into  a  quiet  sleep  of  an 
hour  or  more,  or  he  is  obliged  to  get  up  tired  and  irritable. 
This  sleeplessness,  like  the  vertigo  we  have  already  consid- 
ered, is  often  induced  by  particular  articles  of  diet,  or  by 
some  unwholesome  combination  of  them.     What  will  ex- 


CHAP.  X.]  LIVER  DISTURBANCE.  199 

cite  headache,  giddiness,  or  disorders  of  the  circulation  in 
some  patients,  will  in  another  cause  sleeplessness.  Some- 
times, however,  this  symptom  will  occur  when  the  patient 
is  most  careful  as  to  diet.  What  is  important  also  to  note 
is,  that  in  most  of  these  cases  there  are  no  obvious  symp- 
toms of  gastric  dyspepsia;  the  appetite  may  be  good,  too 
good  in  fact;  the  bowels  may  be  regular;  and  there  may 
be  no  pain,  flatulence,  or  other  discomfort,  after  meals; 
but  there  will  be  found  an  unusual  tendency  to  the  deposit 
of  lithates  in  the  urine,  and  very  often  other  phenomena  of 
a  so-called  gouty  diathesis."  Such  is  a  brief  summary  of 
the  phenomena  associated  with  sleeplessness,  when  the 
patient  is  not  otherwise  ill;  in  the  less  grave  cases  indeed. 
Such  are  then  the  disturbances  of  a  neurosal  nature, 
which  belong  alike  to  biliousness,  and  to  lithtemia,  or  lithia- 
sis.  Whether  it  is  bile-acids,  or  lithates,  which  are  the 
disturbing  matter,  the  phenomena  are  much  alike  as  re- 
gards the  subjective  sensations;  instead  of  the  buoyant 
sensations,  the  sense  of  energy  given  by  the  normal  pro- 
ducts of  digestion,  there  is  depression  and  panphobia,  the 
outcomes  of  a  blood  laden  with  abnormal  products,  or  with 
natural  products  of  albuminoid  metabolism  in  excess.  As 
they  will  be  referred  to  in  the  next  section,  it  will  not  be 
necessary  to  write  them  here.  Such  then  is  a  bird's  eye 
view  of  the  symptoms  produced,  when  the  liver  is  embar- 
rassed or  hindered  in  its  working,  either  by  too  much  to 
do  from  too  many  albuminoids  being  taken  in  the  food,  or 
by  some  cause  of  disturbance  to  its  functional  activity.  It 
fails  to  elaborate  the  products  of  gastro-intestinal  diges- 
tion as  it  ought  uorrnally  to  do;  while  it  produces  bile- 


200  LIVER  DISTURBANCE.  [chap.  x. 

acids  in  excess,  or  it  conducts  the  metabolism  of  the 
digested  proteids  on  a  downward  course,  splitting  them  up 
into  uric  acid  and  urates.  It  is  a  deeply  entrancing  sub- 
ject this,  of  how  the  liver  acts  upon  the  digested  proteids, 
instead  of  further  elaborating  them,  so  as  to  furnish  pabu- 
lum to  the  tissues;  it  arrests  their  further  progress  and 
sends  them  prematurely  on  a  retrograde  career,  splitting 
them  up  into  bile  or  urine  solids.  It  is  like  a  batch  of 
bread  spoiled  in  the  baker's  oven.  The  flour  and  water 
have  been  well  mixed,  the  yeast  incorporated  therewith; 
the  fermenting  action  of  the  yeast  is  operating  on  the 
starch  granules;  the  dough  is  rising  nicely;  it  is  cut  into 
loaves  and  placed  in  the  oven.  But  the  oven  is  too  hot  or 
too  cold,  and  instead  of  wholesome  nutritious  bread,  we 
get  a  sodden,  or  burnt  mass,  unfit  for  food,  and  only  so 
much  good  material  converted  into  waste;  we  all  know  the 
stout-hearted  determination  of  the  youth  "  to  make  a  spoon 
or  spoil  a  horn  !  "  In  this  case  it  is  a  promising  horn 
spoiled  and  no  spoon  made  !  The  peptones  are  wasted; 
instead  of  tissue-pabulum,  they  are  turned  aside  to  under- 
go a  retrograde  metamorphosis  by  a  jDremature  oxidation. 
The  aborted  proteids  only  furnish  so  much  waste  matter, 
which  the  system  must  get  rid  of  as  excrementitious 
material.  Instead  of  so  much  pabulum  to  the  tissues, 
there  is  only  so  much  waste  matter  to  be  eliminated. 

The  management,  medicinal  and  dietetic,  of  this  condi- 
tion will  be  given  in  the  next  chapter. 

A  less  pronounced  condition  than  this  just  described,  has 
been  very  commonly  seen  in  the  recent  east  winds,  which 
proved  so  disastrous  to  the  late  Lord  Beaconsfield;  and  in 


CHAP.  X.]  LIVER  DISTURBANCE.  201 

the  persistent  north-east  wind  which  prevailed  throughout 
May,  1880. 

They  found  out  every  person  who  "  had  a  liver,"  without 
respect  to  persons.  Patient  after  patient  at  the  hospital 
had  to  have  the  plan  of  treatment  arrested  for  a  time,  in 
favor  of  one  adapted  to  the  intercurrent  state  of  liver  dis- 
turbance. Private  patients  required  the  same  "  change  of 
front."  Tlie  east  wind  finds  out  tlie  liver,  albeit  it  lies 
snugly  ensconced  under  the  diaphragm  and  protected  by  the 
abdominal  walls  ;  and  the  expression  "  a  bilious  chill,"  ex- 
tends from  an  acute  condition,  resembling  a  cold  in  dura- 
tion, to  a  more  persisting  state.  Xor  is  the  expression  an 
"undesirable  one  ;  though  it  has  been  sharply  criticised  by 
some.  The  patient  complains  of  malaise,  of  incapacity  for 
exertion,  bodily  toil  is  taxing,  mental  work  is  irksome  ; 
they  are  unfitted  too,  for  their  usual  occupation.  The 
bowels  are  more  or  less  disturbed,  loose  or  constipated; 
there  is  a  bad  taste  in  the  mouth,  and  the  tongue  has  more 
or  less  a  brown-hued  fur  upon  it.  The  urine  is  either 
high-colored  and  dense,  or  laden  with  lithates,  according 
as  the  liver  is  capable  of  converting  the  nitrogenized  waste 
into  urea,  or  only  splitting  up  the  peptones  into  uric  acid 
and  urates. 

Here  again  the  nutrition  was  affected  and  the  peptones 
diverted  from  their  normal  course,  and  turned  to  destruc- 
tion,— wrecked  on  the  way,  indeed.  In  all  cases  iron  and 
tonics  had  to  be  withdrawn,  and  hepatic  stimulants  and 
laxatives,  with  a  restricted  dietary,  substituted  therefor. 
It  was  clear  the  liver  was  incapacitated  for  the  time  from 
taking  any  part  in  the  elaboration  of  the  crude  products 


202  LIVER  DISTURBANCE.  [chap.  x. 

produced  in  the  digestive  canal.  In  some  cases,  but  not 
in  all,  there  was  some  pain  and  distention  experienced  in 
the  region  of  the  liver.  In  all,  without  exception,  there 
was  more  or  less  of  that  cerebral  irritation,  that  mental 
disquietude,  which  has  been  described  earlier  on  as  being 
the  outcome  of  disturbance  in  the  function  of  the  liver. 


CHAPTER  XI. 

PHENOMENA  OF  LIVER  DISTURBANCE  {Continued). 
LIVER  INDIGESTION. 

Whex  Dr,  Murchison  delivered  his  Croonian  Lectures  be- 
fore the  Itoval  Colleo-e  of  Physicians,  and  came  to  the 
subject  of  ^'Abnormal  Disintegration,"  he  said: — "I  need 
not  remind  an  audience  such  as  that  which  I  have  the 
honour  to  address,  that  deposits  in  the  urine  of  lithic 
acid,  or  lithates,  are  not  due  to  any  morbid  condition  of 
the  kidneys.  What  I  wish  to  insist  is,  that  the  frequent 
occurrence  of  these  deposits  in  the  urine  ought  always  to 
be  reofarded  as  a  sis^n  of  functional  derana^ement  of  the 
liver,  arising  from  causes,  sometimes  temporary,  at  other 
times  more  or  less  permanent."  This  is  a  positive  ex- 
pression of  opinion,  clear  and  decisive. 

These  deposits  in  the  urine  are,  then,  significant  of  dis- 
ordered functions  in  the  liver.  Thev  belono-  to  indigestion 
proper.  They  were  held,  are  perhaps  held  still  by  some, 
to  be  the  evidences  of  kidney  disease.  "  Gravel"  of  course 
indicated  kidney  mischief,  and  "sand"  was  a  form  of 
gravel !  Diuretics  and  potash  gave  relief,  and  these 
agents  acted  upon  the  kidneys;  could  the  evidence  be 
more  complete?  Yes,  it  is  true  that  to  give  potash  is 
to  give  relief.  With  potash  uric  acid  makes  a  most  sol- 
uble salt,  and  in  such  combination  uric  acid  is  readily 
drained  out  of  the  blood. 

To  illustrate  the  action  of  potash,  it  is  enough  to  add 


204  LIVER  DISTURBANCE.  [ch.aj'.  xi. 

some  liquor  potassse  to  a  specimen  of  urine  turbid  from 
litbates;  it  quickly  clears.  The  stronger  base  potash 
ousts  the  soda  and  ammonia  from  their  union  witli  the 
uric  acid,  forms  with  it  a  soluble  salt;  and  the  turbid 
urine  becomes  clear.  Could  anything  be  more  delight- 
fully simple! 

But  it  is  not  the  mere  excretion  of  uric  acid  that  we 
have  to  deal  with;  it  is  the  more  important  as  well  as 
more  remote  matter,  its  formation  in  the  system,  which 
we  wash  to  influence.  To  go  back  to  our  analogy  of  the 
thunder-storm,  it  is  not  enouo-h  to  study  the  lio-htnino-  and 
the  thunder;  we  must  proceed  to  investigate  the  genesis 
of  the  storm,  to  consider  the  forces  which  brought  it  aboui;. 
To  dissolve  out  the  offending  uric  acid  by  potash,  is  like 
putting  up  a  lightning  conductor — -a  very  useful  thing  ia 
its  way;  the  utility  of  which  I  have  no  wish  to  und-er-esti- 
mate.  But  no  simile  runs  on  all-fours:  and  though  the 
administration  of  potash  may  be  analogous  to  the  light- 
ning-rod, we  can  influence  the  genesis  of  the  lithiasis;  if 
we  cannot  yet,  in  the  present  state  of  our  knowledge, 
exercise  any  control  over  the  production  of  the  thunder- 
storm. A  little  while  ago,  we  knew  no  more  how  to  do 
this,  than  w-e  yet  know  how  to  abort  a  thunder-storm. 

It  has  long  been  held  that  uric  acid  is  the  poison  of 
gout;  and  Prof.  Garrod  has  demonstrated  that  it  is  "gout 
poison," ^jx:/?*  excellence.  But  while  granting  this,  there  is  a 
form  of  indigestion  of  which  the  abnormal  formation  of 
lithic  acid  and  lithates  is  a  prominent  symptom,  which 
should  rather  be  classed  under  the  head  of  "liver  indiges- 
tion," than  that  of  "gout."     The  two   overlap,  and   the 


CHAT.  XI.]  LIVER  DISTURBANCE.  205 

old  phrase  "  liver  and  kidneys,"  if  vague,  was  certainly 
not  inaccurate.  To  formulate  ''what  is  gout?"  I  should 
make  the  essay  to  this  effect  : — Gout  is  due  primarily  to 
functional  derangement  of  the  liver  in  the  splitting  up  of 
albuminoids;  the  blood  is  surcharged  with  nitrogenised 
waste,  and  this  in  time  leads  to  structural  changes  in  the 
kidneys  !  But  there  is  a  form  of  lithiasis,  which  is  more 
properly  to  be  considered  a  liver  derangement  than  gout. 
"  Gout  "  is  a  term  which  will  be  made  to  embrace  a  wide 
area  in  Part  II.:  and  it  need  not  be  undulv  extended  bv 
includino-  "  liver  indiofestion  "  under  that  headins*.  "When 
gout  is  described,  it  will  be  necessary  to  revert  to  this 
matter;  but  it  need  not  further  engage  our  attention  at  the 
present  stage  of  the  enquiry. 

In  speaking  of  uric  acid,  M.  Foster  says  : — ''  This,  like 
urea,  is  a  normal  constituent  of  urine,  and,  like  urea,  has 
been  found  in  the  blood,  and  in  the  liver  and  spleen.  By 
oxidation,  a  molecule  of  uric  acid  can  be  split  up  into  two 
molecules  of  urea,  and  a  molecule  of  mesoxalic  acid.  It 
may,  therefore,  be  spoken  of  as  a  less  oxidised  form  of  a 
proteid  metabolite  than  urea;  but  there  is  no  evidence 
whatever  to  shew  that  the  former  is  a  necessary  ante- 
cedent of  the  latter;  on  the  contrary,  all  the  facts  known 
go  to  shew  that  the  appearance  of  uric  acid  is  the  result  of 
a  metabolism  slio-htlv  divero-inor-  from  that  leadino-  to  urea." 
It  must,  then,  be  regarded  as  the  product  of  perverted 
metabolism  in  the  liver.  Prout  held  uric  acid  to  have 
another  source  than  urea,  to  be  formed  larofelv  from  the 
gelatinous  forms  of  our  albuminoid  food,  while  urea  was 
held  to   be    derived    from    ordinary    albuminoid   matters. 


206  LIVER  DISTURBANCE.  [chap.  xi. 

This  view  was  soon  abandoned,  and  it  was  thought  uric 
acid  was  a  normal  product,  viz.,  a  sort  of  nitrogenised  waste 
preceding  urea,  and  converted  into  urea  by  further  oxida- 
tion; or  by  a  splitting  up  into  urea  and  oxalic  acid.  Now 
we  regard  it  as  a  product  of  perverted  metabolism  in  the 
liver.  The  appearance  of  lithates  in  abundance  in  the 
urine,  about  the  time  when  the  liver  is  actively  engaged 
in  the  digestive  process,  renders  it  highly  probable  that 
certain  peptones,  instead  of  undergoing  further  elabora- 
tion, are  turned  aside,  and  broken  up  prematurely  into 
lithic  acid  and  lithates.  That  these  lithates  do  not  in 
any  way  represent  tissue  waste,  for  they  have  never  been 
tissues  !  They  stand  in  the  same  relations  to-  the  tissues 
that  a  still-born  child  bears  to  an  estate  it  would  have 
inherited,  had  it  been  born  living  and  viable.  So  the 
material  which  forms  uric  acid  might  have  been  tissue 
under  more  favourable  circumstances.  Such  is  the  posi- 
tion, to  put  it  broadly. 

Now  as  to  the  clinical  relations  of  these  lithates,  the 
outcomes  of  perverted  metabolism  in  the  liver,  in  other 
words,  the  products  of  "  liver-indigestion."  In  the  article 
on  "  Biliousness,"  referred  to  before  in  the  earlier  section 
of  this  article,  is  written: — "Biliousness  may  take  one  of 
two  directions.  In  some  persons  there  is  the  regular 
bilious  attack, — headache,  furred  tongue,  disturbance  of 
the  alimentary  canal,  vitiated  stools,  and  fulness  over  the 
hepatic  region,  the  urine  being  merely  high  coloured.  In 
others,  again,  there  is  rather  a  dyspeptic  condition,  with 
the  appearance  of  lithates  in  the  water,  especially  two  or 
three  hours  after  a  meal.     There  is  no  essential  difference 


CHAT.  XI.]  LIVER  DISTURBANCE.  207 

betwixt  the  two;  in  each  there  is  defective  oxidation.  But 
in  the  one  tlie  bile-acids  seem  to  preponderate,  while  in 
the  other  the  urinary  products  of  nitrogenised  waste  take 
the  leading  place.  The  first  is  rather  the  condition  of  the 
congenitally  bilious,  the  latter  of  the  congenitally  gouty." 
This  division,  further  experience  corroborates,  and  it  seems 
really  a  fairly  correct  one.  It  may  be  questioned,  how- 
ever, whether  the  expression — "in  each  there  is  defective 
oxidation  " — does  not  require  a  little  explanation.  "  Defec- 
tive oxidation"  is  found  in  both  states,  but  the  conditions 
do  not  depend  for  their  production  on  defective  oxidation 
solely;  there  is  the  perverted  metabolism  as  well.  But 
both  ai%  outcomes  of  liver  disturbance,  linked  with  defec- 
tive oxidation;  and  the  offending  matters  are  alike  of 
albuminoid  origin  and  descent. 

Uric  acid,  as  has  often  been  pointed  out,  is  found  alike 
in  birds  of  a  high  temperature,  and  in  cold-blooded  rep- 
tiles; and,  therefore,  is  not  due  to  defective  oxidation 
merel}".  It  is  rather  the  form  of  excreted  urine  solids 
suited  to  ''  solid  "  urine;  while  urea  is  the  form  found 
in  "fluid"  urine  (M.  Foster).  Dr.  Henry  Bennett,  in  his 
valuable  work  on  "  Nutrition  in  Health  and  Disease," 
2nd  Edit.,  1876,  Avrites  : — "  I  have  repeatedly  alluded  to 
the  presence  of  morbid  salts  in  the  urine  as  a  result 
and  an  evidence  of  imperfect  digestion.  I  believe  their 
presence  to  be  the  most  delicate  and  most  easily  recog- 
nised test  that  we  can  brino;  to  bear  in  the  dias^nosis  of 
defective  digestion;  and  I  am  also  of  opinion  tliat  its 
value,  though  recognised,  has  not  been  fully  appreciated 
by  the  profession.     They  consist  principally  of  uric  acid. 


208  LIVER  DISTURBANCE.  [chap.  xi. 

urate  of  ammonia,  purpurine  or  colouring  matter,  oxalate 
of  limej  the  triple  phosphates,  the  neutral  phosphate  of 
lime,  pus  or  blood  globules,  epithelial  scales,  and  fibrinous 
casts  of  the  uriniferous  tubules  of  the  kidnev."  Thus  we 
see  uric,  or  lithic  acid,  alone,  or  combined  with  ammonia, 
stands  first,  and  after  that  the  phosphates.  *'  Phosphatic 
deposits  are  principally  observed  in  those  persons  in  whom 
the  nervous  system  has  been  too  greatly  and  too  continu- 
ously used,  and  the  general  vitality  thereby  lowered.  When 
this  is  the  case,  there  is  of  course  a  more  rapid  disintegra- 
tion of  the  phosphatic  salts  which  enter  so  largely  into  the 
structure  of  the  brain,  and  of  the  nervous  system  generally. 
The  acid  phosphate,  which,  by  its  reaction  on  the  triple 
phosphate  and  the  phosphate  of  lime  in  the  healthy  urine, 
secures  its  solution,  is  no  longer  in  sufficient  quantity  to 
prevent  the  precipitation  of  the  abnormally  abundant  phos- 
phates, and  they  are  thus  more  or  less  copiouslj^  de- 
posited." It  is  not  yet  possible  to  sa}^  very  much  on  this 
subject,  but  the  relation  of  phosphatic  deposits  to  disturb- 
ance in  the  nervous  system  stands  in  a  most  suggestive 
relationship  to  the  formation  of  lecithin;  the  phosphorus 
of  which  is  normally  derived  from  the  phosphates  of  our 
food.     Further  than  this  may  not  be  affirmed. 

He  proceeds  in  this  matter  by  making  the  observations: 
— "  Sufficient  time,  also,  must  be  allowed  to  pass  for  the 
processes  of  digestion  to  be  accomplished,  and  for  the  chyle 
to  reach  the  blood.  As  soon  as  the  chyle  has  reached  the 
circulation,  the  kidneys  commence  their  function  of  filtra- 
tion and  elimination,  if  it  is  unfit  for  assimilation.  This 
elimination  they  continue  until  the  blood  is  thoroughly 


CHAP.  XT.]  LIVER  DISTURBANCE.  209 

purified.  Thus,  for  some  hours  after  the  ingestion  of  food 
by  a  dyspeptic  patient,  the  urine  will  remain  clear,  because 
the  ch^'le  has  not  reached  the  circulating  fluid.  Then  for 
a  longer  or  shorter  time  it  becomes  turbid,  and  throws 
down  in  cooling  a  deposit  of  pinkish  or  pale  hue  owing 
to  its  beino-  loaded  with  urate  of  ammonia.  In  the  same 
specimen  will  constantly  be  found,  on  microscopical  exam- 
ination, uric  acid,  oxalate  of  lime,  or  phosphatic  salts. 
After  this  it  again  becomes  clear,  because  the  blood  has 
been  purified  of  the  impure  chyle,  and  the  urine  has 
reverted  to  its  normal  character."  Here  we  see  Dr. 
Bennett  speak  of  the  higher  processes  of  digestion,  viz., 
when  the  matters  rendered  soluble  by  the  digestion  in  the 
alimentary  canal  have  entered  the  blood  as  "  chyle."  A 
younger  man  would  probably  use  a  more  modern  nomen- 
clature. He  goes  on — "  Such  being  the  case,  to  test  the 
digestion  of  food  by  the  state  of  the  urine;  we  must  ex- 
amine that'whicli  is  secreted  by  the  kidney  during  the  hour 
or  two  which  follows  the  completion  of  digestion,  and  the 
entrance  of  the  chyle  into  the  blood.  This  period  varies  of 
course,  accordino-  to  the  leno;th  of  time  that  the  food  in- 
gested  takes  to  digest,  which  itself  varies,  as  we  have  seen, 
according  to  the  nature  of  the  food,  and  according  to  indi- 
vidual peculiarities.  Milk,  eggs,  vegetables,  fish,  etc.,  take 
about  two  hours;  so  the  urine  should  be  examined  two  or 
three  hours  after  their  ingestion.  Fowl,  game,  beef,  veal, 
etc.,  take  from  two  to  three  or  four  hours.  With  some 
persons  the  stomachal  and  intestinal  digestion  is  so  slow 
that  a  much  longer  time  elapses  before  the  chyle  reaches 
the  blood,  and  is  thus  abnormally  eliminated  by  the  kid- 


210 


LIVER  DISTURBANCE.  [chap.  xi. 


iieys.  In  others  the  digestive  processes,  on  the  contrary, 
are  very  rapid,  and  the  morbid  deposits  must  be  sought  for 
at  an  earlier  period." 

It  will  now  be  clear  and  intelligible  to  the  reader  why  I 
did  not  discuss  the  urine  and  its  modifications  earlier  on 
under  ordinary  indigestion.    Urine  deposits  belong  to  that 
part  of  the  digestive  act  .which  goes  on  after  the  soluble 
matters  have  entered  the  blood;   not  with  that  part  which 
relates  to  rendering  the  food  soluble.     They  have  entered 
the  blood,  and  here  the  digestive  act  in  the  alimentary 
canal  has  performed  its  part,  and  is  over  and  past.     It  is 
with  the  metabolism  after  the  products  of  digestion  have 
entered  the  portal   circulation  that  urinary  deposits  are 
concerned.     Therefore  they  do  not  belong  to  the  first  forms 
of  indio-estion,  but  to  the  latter,  or  "liver  indigestion;" 
and  must  be  considered  in  the  section  devoted  to  this  last 
matter  and  its  disturbances.    Consequently,  as  Dr.  Bennett 
insists,  a  certain  time  must  be  allowed  to  elapse  after  a 
meal  before  the  urine  is  examined  for  the  mal-products  of 
disordered  assimilation.     He  holds  that,  even  in  pyrexia, 
the. deposit  of  lithates,  so  well  known  at  the  breaking  of  a 
common  cold,  "is  in  a  great  measure  owing  to  the  imper- 
fect dio-estion  and  assimilation  of  the  food  given,  and  not  to 
the  retrograde  metamorphosis  of  the  nitrogenised  tissues." 
A  view  which  has  much  to  recommend  it  to  the  attention 
of  the  profession. 

He  proceeds — "  Uric  acid  crystals  are  found  more  or  less 
abundantly  under  the  same  circumstances  as  the  double 
urates,  and  often  in  the  same  patients.  I  have  in  vain 
endeavored,    in    some  cases,   to    find  a  distinct  cause   or 


CHAP.  XI.]  LIVER  DISTURBANCE.  211 

reason  for  their  absence;  as  also  their  appearance  and  dis- 
appearance in  tlie  same  person.  Their  constant  existence 
undoubtedly  indicates  a  more  decidedly  depraved  state  of 
tlie  digestive  functions,  and  a  more  debilitated,  broken- 
down  condition  of  the  general  health  than  is  shown  by 
the  presence  of  urate  of  ammonia  alone.  It  is  frequently 
observed  in  persons  presenting  the  gouty  or  rheumatic 
diathesis  or  constitution."  "We  will  follow  Dr.  Bennett  to 
his  conclusion — "lam  thus  disposed  to  think  that  the 
presence  of  uric  acid  and  of  lithates  in  the  urine  in  such 
abnormal  quantities  as  to  constitute  a  de]3osit,  is  very 
much  more  frequently  the  result  of  defective  digestion  than 
defective  metamorphosis  of  tissue,  especially  in  dyspeptic 
individuals.  This  is  not  the  generally  received  opinion, 
but  that  it  is  really  the  case  appears  to  me  evident,  from 
the  circumstances  that  I  am  able,  in  the  majority  of  such 
cases,  to  trace  them  to  the  food  digested  a  few  hours  pre- 
viously, and  that  they  disappear  from  the  urine  secreted 
after  a  prolonged  fast."  Dr.  Bennett  has  made  such  careful 
study  of  the  modifications  produced  in  the  urine  by  in- 
digestion, that  I  put  his  views  before  the  reader  at  some 
leno-th,  believinor  them  to  be  worthv  of  all  attention. 

Dr.  Murchison  delivers  himself  as  follows,  as  to  the  pro- 
duction of  uric,  or  lithic  acid,  and  lithates. 

"  Excluding  those  cases  in  which  deposits  of  lithic  acid 
or  lithates  are  thrown  down  in  the  urine  not  until  twelve 
or  twenty  hours  after  its  emission,  as  the  result  of  spon- 
taneous changes,  to  which  Scherer  has  given  the  name  of 
acid  urinary  fermentation,  and  those  which  are  due  to  a 
marked  deficiency  of  urinary  water,  deposits  of  lithic  acid, 


212  LIVER  DISTURBANCE.  [chap.  xi. 

lithates  and  abnormal  pigments  which  appear  in  the  urine 
as  soon  as  it  cools,  are  chiefly  met  with  under  the  follow- 
ing conditions: — 

"  1.  In  febrile  diseases,  in  which  we  know  that  the  liver 
becomes  enlarged  and  congested,  and  its  gland-cells  loaded 
with  minute  granules,"  and  in  which  there  always  is  an 
increased  disintegration  of  albuminous  matter.  Every  one, 
for  example,  is  familiar  with  the  copious  deposits  of  lith- 
ates which  are  so  common  during  an  attack  of  ordinary 
febrile  catarrh. 

"  2.  In  many  structural  diseases  of  the  liver,  and  particu- 
larly in  those  which  are  characterised  by  an  increased 
amount  of  blood  in  the  organ,  such  as  inflammation,  cir- 
rhosis, cancer,  and  simple  hypersemia,  whether  mechanical 
or  active. 

"3.  In  functional  derangement  of  the  liver,  either  tem- 
2:)orary  or  persistent. 

"  Lithuria,  like  glycosuria,  is  very  often  due  to  a  function- 
al disease  of  the  liver.  Although  even  glycosuria  is  still 
ranared  in  some  text-books  with  albuminuria  and  diseases 
of  the  kidney.  In  other  words,  abnormal  disintegration 
of  albuminous  matter  in  the  liver  may  lead  to  a  morbid 
condition  of  the  blood  and  of  the  entire  system,  which 
often  manifests  itself  in  lithuria." 

Now  a  very  well  marked  instance  of  the  second  division 
of  Dr.  Murchison,  including  "simple  hyperaemia,  whether 
mechanical  or  active,"  is  seen  in  the  urine  in  cardiac 
dropsy. 

As  the  heart  fails  in  power  the  bulk  of  urine  falls  pari 
passu.     The   bulk  of  urine  is  in  strict  proportion  to  the 


CHAP.  XI.]  LIVER  DISTURBANCE.  213 

blood-j^rcssure  in  tlic  arteries;  and  this,  again,  to  the 
vigour  with  which  the  heart  pumps  the  blood  into  the 
arterial  system.  "When  the  heart  begins  to  fail  the  blood 
is  less  vigorously  pumped  into  the  arteries,  the  blood- 
pressure  then  falls,  in  the  kidney  as  elsewhere,  and  with 
it  the  bulk  of  the  urine,  in  other  words  the  amount  of 
water  passed.  This  morbid  change  may  proceed  a  con- 
siderable leno'th  w^ithout  the  urine  beins;  otherwise  altered 
than  beins:  scantv  and  dense,  or  concentrated.  But  when 
the  liver  becomes  involved  in  the  venous  fulness,  and 
begins  to  enlarge  from  passive  congestion,  then  the  urine 
chanofes.  It  now  contains  lithates  in  abundance,  fawn- 
coloured,  or  pink,  sometimes  more  than  pink.  The  con- 
gestion of  the  liver  interferes  with  its  functional  activit}'", 
and  then  lithates  appear  in  the  water, — the  proof  of  the 
deranorement  of  the  function  of  the  liver. 

This  is  the  more  liable  to  happen  when  the  plan  of  treat- 
ment adopted  is  a  very  "  sustaining  "  one.  The  patient 
is  encouraged  to  take  the  most  strengthening  "  things," 
that  is,  albuminoids  in  as  great  quantity  as  possible,  and 
then  the  crippled  liver  is  unequal  to  carrying  on  the 
ordinary  metabolism,  and  lithates  make  their  appearance. 
The  association  of  such  lithates  with  the  disablement  (more 
or  less)  of  the  liver,  ought  to  be  made  a  point  of  impor- 
tance in  the  dietetic  management  of  the  case.  In  the  face 
of  such  evidence  it  is  of  the  most  questionable  utility  to 
force  albuminoids  upon  the  patients,  when  the  liver  is  thus 
evidently  unequal  to  dealing  with  them;  and  the  dietary 
should  be  modified,  and  made  projDortionate  to  the  reduced 
power  of  the  liver,  gorged  with  venous  blood. 


214  LIVER  DISTURBANCE,  [chap.  xi. 

Of  course  a  dense  urine  is  apt  to  deposit  urates  after 
being  passed  some  time,  especially  in  cold  weather.  But 
still  there  is  the  difference  betwixt  the  dense,  high  col- 
oured urine,  which  remains  clear  for  a  considerable  time, 
and  the  urine  which  becomes  turbid  with  urates  shortly 
after  being  passed.  The  latter  tells  clearly  of  functional 
embarrassment  of  the  liver. 

As  reg-ards  the  colour  of  the  urates  thrown  down  much 
might  be  said.  "  The  frequent  or  constant  occurrence  of 
a  brownish  or  red  urate  deposit  without  or  with  only  a 
feeble  degree  of  pyrexia,  is  a  circumstance  to  awaken  sus- 
picions of  some  serious  organic  disease;  but  the  indica- 
tion is  more  general  than  special.  Organic  disease  of  the 
lungs,  heart,  liver,  spleen,  or  other  part,  attended  with 
emaciation  and  waste  of  the  tissues,  is  usually  accom- 
panied with  abundant  deep-coloured  urate  deposit.  Func- 
tional derangements  of  the  digestive  organs  are  also 
generally  accompanied  by  pale  urate  deposits  in  the  urine  " 
(W.  Roberts).  This  is  an  observation  not  without  much 
clinical  value.  Many  old  j^ractitioners  observe  the  colour 
of  the  urine  deposits  very  carefully.  There  is  a  general 
consensus  of  oj)inion  that  the  pale-coloured,  chalky  look- 
ing deposits  are  found  along  with  indigestion;  especially 
those  deposits  found  from  two  to  five  hours  after  a  meal, 
as  described  by  Dr.  Henry  Bennett.  On  the  other  hand 
deep-coloured  pink,  or  even  crimson  deposits  are  rather 
found  usually  in  old  gouty  subjects;  at  least,  in  my  ex- 
perience. Nor  is  the  matter  one  to  be  dismissed  as  of 
little,  or  no  practical  importance.  The  production  of  bili- 
rubin, or  the  non-production  of  it  may  depend  upon  states 


CHAP.  XI.]  LIVER  BISTURBAN'CE.  215 

of  the  liver  which  differ  considerably.  AVhile  not  wishing 
to  be  too  precise,  it  may  be  said  that  in  acute  liver- 
indi":estion  there  is  little  bilirubin  found  from  which  the 
urine  colouring"  matter  is  derived;  in  old  gouty  cases  it  is 
freely  produced.  This  may  indicate  a  difference  in  the 
metabolism  going  on  in  the  liver.  Again,  we  approach 
the  border-lands,  the  frontier  of  the  agonosphere, — the 
unknown  which  possesses  so  much  interest  for  us. 
Uric  acid  is  generally  regarded  as  indicating  another  state 
of  affairs,  though  Dr.  Bennett  thinks  it  a  difference  of  de- 
gree, indicating  a  more  pronounced  morbid  state;  while 
Roberts  remarks  as  follows  : — "  There  is  this  difference 
between  the  conditions  favourable  to  the  deposit  of  free 
uric  acid  and  the  amorphous  urates — that  a  high  density 
(or  concentration)  favours  the  latter,  and  a  low  density 
(or  dilution)  favours  the  former."  Thus  making  it  largely 
a  matter  of  solution  or  density.  This  difference  of  opinion 
illustrates  that  the  subject  is  as  yet  far  from  being  settled 
definitely. 

Connected  with  the  relations  of  the  urine  to  conditions 
of  functional  disorder  of  the  liver,  stands  azoturia  or 
baruria,  as  it  has  been  termed  by  various  writers;  in. 
which  there  is  an  excess  of  urea  in  the  urine.  Prout 
first  described  it,  and  Willis  followed  him.  Prout  divided 
these  cases  into  "excess  of  urea  icithoiit  diuresis,  and  excess 
of  urea  with  diuresis.^''  In  the  first,  though  there  is  great 
susceptibility  to  derangement,  as  well  as  to  actual  disease 
of  the  assimilating  and  other  functions,  I  am  not  aware 
that  any  one  derangement  of  any  one  organ  can  with  cer- 
tainty be  pronounced  to  be  characteristic  of  an  excess  of 


216  LIVER  DISTURBANCE.  [chap.  xi. 

urea  in  the  urine.  In  the  second,  modifications  of  tlie 
disease,  in  which  the  quantity  passed  is  excessive;  besides 
most  of  the  symptoms  above  enumerated  in  an  aggravated 
form,  there  exists,  in  addition,  more  or  less  of  thirst  and 
morbid  craving  after  food.  The  patient  likewise  complains 
of  general  coldness  and  great  bodily  weakness.  In  some  in- 
stances also,  there  is  considerable  emaciation;  though  not 
to  the  same  remarkable  extent  as  in  diabetes.  The  causes 
predisposing  to  an  excess  of  urea  in  the  urine  seem  to 
be  nearly  allied  to  those  predisposing  to  diabetes.  Most 
of  the  subjects  of  the  disease  in  the  forms  above  described, 
have  been  middle-aged  men,  of  sj)are  thin  habit,  with  a  sort 
of  hollow-eyed  anxiety  of  expression  on  their  counte- 
nance; unusually  nervous  and  susceptible,  but  by  no  means 
always  hypochondriacal;  and  also  free  from  gout,  and, as  far 
as  could  be  ascertained,  from  structural  disease  of  the  urin- 
ary or  any  other  organs.  With  respect  to  the  ^Droximate 
cause  or  intimate  nature  of  the  disease,  I  have  been  long 
of  the  opinion  that  it  depends  upon  derangements  of  the 
secondary  assimilating  processes,  rather  than  the  primary." 
Having  related  a  case  at  some  length,  where  the  patient  so 
largely  recovered  as  to  be  practically  well,  he  goes  on: — • 
"  The  second  case  I  shall  recite  is  one  that  occurred  to 
Dr.  Elliotson,  at  St.  Thomas's  Hospital;  who  furnished 
me  with  the  urine  for  examination  every  week,  so  as  to 
enable  me  to  ascertain  the  effects  of  the  remedies  employed. 
March  5th,  1819.  Rodman,  aged  fifty-five.  Symptoms 
resembling  diabetes.  There  is  a  constant  craving  for  food, 
a  sense  of  cold  over  the  whole  body,  and  a  frequent  desire 
of  passing  urine,  which  in  twent3^-four  hours  amounts  to 


CHAP.  XI.]  LIVER  DISTURBANCE.  217 

sixteen  pi  Jits.  The  urine  of  this  man  was  pale-coloured; 
its  specific  gravity  was  1.020;  and  it  contained  a  very 
larg-e  proportion  of  urea  ;  but  not  the  least  particle  of 
saccharine  matter.  On  standing,  it  also  deposited  crys- 
tals of  lithic  acid.  Ordered  opii.  gr.  1^  bis  die  (opium 
in  this  case  was  ordered  by  Dr.  E.,  on  the  supposition  the 
disease  was  diabetes).  March  20th. — Feels  much  better. 
Urine  reduced  to  two  pints  in  twenty-four  hours.  Pergat. 
The  urine  was  now  somewhat  deeper  coloured  ;  and  de- 
posited a  copious  sediment  consisting  partly  of  lithic  acid 
crystals,  and  partly  of  lateritious  sediment.  Its  sj^ecific 
gravity  was  increased  to  1.0344;  evidently  from  its  having 
become  more  concentrated  than  natural.  The  quantity  of 
urea  was  abundant,  but  not  in  the  proportion  in  which  the 
urine  was  concentrated. 

"The  man  became  so  well  shortly  after  the  above  date, 
that  he  did  not  return  to  the  hospital  till  August  19th. 
Disease  returned  six  weeks  ago.  Feels  as  ill  as  ever — very 
weak.  Bowels  costive.  Quantity  of  urine  in  twenty-four 
hours,  about  four  pints.  Ordered  opium,  as  before.  The 
urine  was  now  transparent.  Its  specific  gravity  was  1.023, 
and  urea  was  abundant.  Under  the  above  plan  he  speedily 
became  better,  and  soon  afterwards  ceased  to  attend  the 
hospital." — ("  On  the  Xature  and  Treatment  of  Stomach 
and  Urinary  Diseases  ;  being  an  Enquiry  into  the  Con- 
nection of  Diabetes,  Calculus,  and  other  Affections  of  the 
Kidney  and  Bladder,  with  Indigestion,"  3rd  Edit.,  1840). 
Wm.  Roberts  thinks,  "  precise  facts  in  support  of  Front's 
view  are  wantins:;  "  but  refers  to  a  case  recorded  bv  the  late 

Dr.  Parkes  ("  On  the  Composition  of  the  Urine,"  p.  374), 
10 


218  LIVER  DISTURBANCE.  [chap.  xi. 

where  a  man,  on  the  ordinary  diet  of  University  College 
Hospital,  passed  1130  grains  of  urea  daily,  and  concludes 
thus: — ''In  my  own  experience,  I  have  usually  found  that 
cases  which  at  first  sight  appeared  to  belong  to  this  cate- 
gory— cases  exhibiting  a  dense  urine  and  a  train  of  ner- 
vous symptoms, — turned  out  on  more  exact  investigation, 
to  want  a  special  feature  indicated  by  Prout  as  the  es- 
sential one  ;  namely,  an  absolute  increase  in  the  daily 
discharge  of  urea.  Nevertheless,  some  facts,  rarely  ob- 
served, have  left  an  impression  on  my  mind  that  Prout's 
description  is  not  altogether  fanciful."  He  then  gives 
notes  of  a  case,  where  more  than  500  grains  of  urea 
were  passed  daily.  In  this  case,  as  in  Parkes',  there  was 
a  trace  of  sugar  present.  As  to  the  causation  of  these 
cases,  Dr.  Roberts  says: — "In  the  case  just  related,  the 
cause  of  the  complaint  was  mental  anxiety;  and  in  all  the 
instances  which  I  have  been  inclined  to  place  in  this  group, 
the  origin  of  the  disorder  could  always  be  traced  to  some 
kind  of  mental  emotion." 

Perhaps  Prout  was  not  far  astray  in  regarding  such 
cases  as  pathologically  related  to  diabetes  ;  and  Roberts 
admits: — "That  there  is  some  relation  between  the  two 
conditions  seems  not  improbable."  Dr.  Handfield  Jones 
has  described  six  cases  of  like  disease  under  the  head  of 
Baruria,  Brit.  3fed.  Jour.,  Oct.  12th,  18G1.  While  the 
late  Dr.  Fuller,  without  acquaintance  with  what  had  been 
done  by  Prout  and  others,  brought  before  the  Medico- 
Chirurgical  Society,  papers  "  On  Excess  of  the  Urea  in 
the  Urine  as  a  Guide  to  Diagnosis  and  Treatment  of 
Certain  Forms   of  Dyspepsia  "   (Trans.,  Vol.  40,  42,  and 


CHAT.  XI.]  LIVER  DISTURBAN-CE.  219 

51);  in  which  he  described  simihir  cases.  Passing  throug-li 
all  of  them  was,  then,  a  history  of  nervous  trouble,  which 
gave  them  a  certain  character  and  generic  resemblance. 
They  stand  in  an  interesting  and  suggestive  relationship 
to  the  excessive  quantity  of  urea  found  in  the  urine  in  the 
early  stages  of  chorea. 

In  connection  with  this  subject,  closely  linked  thereto 
indeed,  stands  Albuminuria.  The  presence  of  albumen 
in  the  urine  is  usually  regarded  as  the  evidence  of  disease 
of  the  kidney.  It  is  not  necessary  to  discuss  the  whole 
subject  here:  it  is  enough  to  say  that  it  is  much  easier  to 
detect  the  presence  of  albumen  in  the  urine,  than  to  know 
what  it  means,  or  what  its  significance  is,  when  it  is  found. 
The  student  is  taught  the  various  means  by  which  a  trace 
of  albumen  may  be  demonstrated  in  the  urine;  but  he  is 
not  taught,  and  in  the  present  state  of  our  knowledge, 
there  is  no  one  who  can  teach  him  what  its  precise  signi- 
ficance is  when  found.  We  know  that  in  certain  con- 
ditions its  presence  is  of  the  most  sinister  omen;  we  have 
learned  that  at  other  times  it  is  devoid  of  sio^nificance. 
I  shall  here  review  merely  its  relation  to  disturbance  of 
the  digestive  organs.  Such  relation  of  albuminuria  was 
entertained  by  the  late  Dr.  Parkes,  who  "  inclined  to  the 
opinion  that  the  liver  plays  an  important  part  in  the  devel- 
opment of  albuminuria;  he  thinks,  through  some  failure 
in  preparation,  either  by  the  stomach  or  the  liver,  albumen 
enters  the  right  side  of  the  heart,  still  in  a  crude  state, 
and  in  a  condition  similar  to  that  introduced  into  the 
jugular  vein  in  Bernard's  experiment."  (Claude  Bernard 
found  that  crude  albumen  injected  into  the  jugular  vein. 


^20  LIVER  DTSTURBAJ^CE.  [chap.  xi. 


produced  temporary  albuminuria).  It  is  well  known,  tliat 
if  two  or  three  raw  eggs  are  eaten  at  once,  albumen  makes 
its  appearance  in  the  urine.  It  would  seem  that  here  the 
quantity  of  crude  albumen  passing  from  the  alimentary 
canal  into  the  blood,  overruns  the  power  of  the  liver  to 
deal  with  it;  and  a  certain  portion  passes  through  the 
liver  in  its  crude  state,  and  as  such  escapes  througli  the 
kidneys.  The  late  Dr.  Basham,  in  discussing  the  presence 
of  albumen  in  the  urine,  wrote: 

"  There  is  yet  another  subject  of  interest  connected  with 
the  long  continuance  of  albumen  in  the  urine;  associated 
as  it  universally  is  with  a  diminution  of  the  urea,  the  lead- 
ing characteristic  of  healthy  urine.  Can  it  be  said  in 
these  cases,  that  the  albumen  is  the  pathological  substitute 
for  urea  ?  The  fact  cannot  here  escape  notice,  that  cases 
frequently  occur  in  which  the  urine  continues  for  months, 
and  even  years,  persistently  albuminous.  I  know  two 
cases  of  near  four  years  duration,  the  patients'  health 
being  fairly  re-established;  all  the  chief  functions  being 
performed  with  undeviating  regularity,  and  with  no  ob- 
vious disorder,  except  in  the  composition  of  the  urine. 
The  character  of  this  being  the  presence  of  albumen,  with 
diminution  of  urea.  Although  we  are  as  yet  without  proof, 
yet  it  has  appeared  to  me  probable,  that  the  albumen  in 
the  urine  (in  these  long-standing  cases)  must,  in  some 
way,  take  the  place  of  urea,  and  become,  as  it  were,  its 
pathological  substitute." 

The  remarks  of  the  late  Dr.  Murchison  are  so  replete 
with  knowledge,  and  given  with  such  judgment,  that  it 
appears  better  to  give  them  verbatim  than  to  attempt  to 


CHAP.  XI.]  LIVER  DISTURBANCE.  221 

condense  them.  "  There  are  also  reasons  for  believing 
that  albuuiinuria  may  be  induced  by  hepatic  derangement 
independently  of  structural  disease  of  the  kidneys.  It  is 
now  generally  acknowledged  that  albuminuria,  even  when 
copious,  and  in  the  absence  of  any  acute  febrile  disorder, 
does  not  necessarily  indicate  renal  disease.  Very  often,  in 
these  cases,  the  albuminuria  is  intermittent  or  remittent, 
and  the  albumen  has  peculiar  chemical  characters;  the 
previous  addition,  for  example,  of  a  few  drops  of  mineral 
acid,  preventing  to  an  unusual  extent  the  subsequent 
coagulability  by  heat.  Errors  in  diet  are  one  of  the  most 
common  causes.  In  some  persons,  peculiarly  constituted, 
temporary  albuminuria  is  a  constant  result  of  certain  arti- 
cles of  food,  such  as  uncooked  eggs.  In  several  instances 
I  have  known  the  urine  passed  at  night  to  contain  albu- 
men, often  associated  with  lithates  and  a  high  specific 
gravity;  whereas  the  morning  urine  was  clear,  of  low  spe- 
cific gravity,  and  contained  no  albumen.  Again,  in  cer- 
tain cases  of  exophthalmic  goitre  the  urine,  at  some  hours 
of  the  day,  usually  after  food,  is  loaded  with  albumen, 
whereas  at  others  it  contains  none;  and  this  state  of  mat- 
ters may  last  for  many  months,  and  then  completely  dis- 
appear. Now,  it  is  not  contended  that  in  all  these  cases 
the  liver  is  the  organ  primarily  at  fault,  but  certainly  in 
some  there  is  good  reason  for  believing  it  to  be  so;  the 
albuminuria  being  unattended  by  any  other  symptom  of 
renal  disease,  varying  greatly  in  quantity  and  sometimes 
absent;  and  the  urine  being  of  normal  quantity,  of  high 
specific  gravit^^,  and  habitually  loaded  with  lithates,  lithic 
acid,  oxalates,  and  pigments;  and  there   being  very  often 


222  LIVER  DISTURBANCE.  [chap.  xi. 

cutaneous  eruptions,  dyspepsia,  and  other  evidence  of  he- 
patic derangement.  I  have  met  with  several  instances  of 
this  sort,  where  the  jDatient  was  subject  to  severe  attacks 
of  what  at  first  seemed  to  be  hej)atic  colic,  but  where 
there  was  no  jaundice,  and  the  paroxysm  was  followed  by 
a  temporary  yet  extraordinary  increase  of  lithates  and 
albumen  in  the  urine.  Lastly,  so  often  have  I  observed 
albuminuria  associated  with  hepatic  disorder,  which  has 
disappeared  completely  and  permanently  when  this  has 
been  set  to  rights,  that  I  have  little  doubt  that  we  have  in 
the  liver  a  cause  of  albuminuria,  to  which  attention  has  not 
3'et  been  sufficiently  directed.  The  pathology  of  the  albu- 
minuria in  these  cases,  may  be  similar  to  that  of  cer- 
tain cases  of  diabetes  already  referred  to,  the  liver  having 
too  much  work  to  do,  and  permitting  some  albumen  to  pass 
through  in  a  form  which  cannot  be  assimilated;  or  possi- 
bly there  may  be  some  defect  in  the  destructive  functions 
of  the  liver,  in  consequence  of  which  the  albuminous  mat- 
ter, instead  of  being  converted  into  urea,  does  not  even 
reach  the  stage  of  lithic  acid.  It  is  possible  that  in  many 
of  the  cases  now  referred  to,  the  albuminuria  may  indicate 
an  early  stage,  not  yet  described,  of  the  contracted  or 
gouty  kidney;  yet  it  is  certain  that  the  symptom  may  per- 
sist or  recur,  during  many  years,  without  any  other  symp- 
tom of  renal  disease  and  with  but  little  impairment  of  the 
general  health." 

What  Dr.  Murchison  says  here,  should  be  well  weighed 
by  every  practitioner,  I  entirely  agree  with  what  is  said; 
and  for  some  time  jDast  I  have  treated  certain  cases  of  al- 
buminuria by  a  farinaceous  non-nitrogenised  dietary,  with 


CHAi^.  XI.]  LIVER  DISTURBANCE.  223 

the  best  effects;  the  patient  feeling  better,  along  with  a 
corresponding  diminution  of  the  amount  of  albumen  in  the 
urine.  It  will  not  do  in  practice  to  run  away  with  the  idea 
that  albuminuria  is  pathognomonic  of  renal  disease;  to  do 
so  is  to  alarm  the  patient  unnecessarily,  and  when  time 
has  disproved  the  doctor's  vaticinations,  to  bring  him  in- 
dividually, and  the  profession  generally,  into  disrepute. 
Nor  is  it  possible  to  plead  that  the  present  views  of  the 
infallibility  of  the  test-tube,  are  justified  by  our  experience; 
laziness  "or  indifference  are  too  large  factors  in  the  present 
attitude  of  slothful  satisfaction,  and  blind  confidence  in 
the  chemical  test, — to  enable  it  to  be  said  that  the  posi- 
tion is  excusable. 

Having  often  elsewhere  entered  my  opinion  on  this  sub- 
ject in  writing,  and  protesting  against  the  abject  attitude 
of  the  profession  at  large,  to  objecting  to  reason  on  the 
phenomena,  but  accepting  the  presence  or  absence  of  albu- 
minuria as  full,  ample,  and  complete  proof  of  the  state  of 
the  kidneys;  of  the  presence  or  absence  of  disease  in  them; 
I  feel  it  desirable,  here,  to  transcribe  the  views  of  others — ■ 
men,  whose  ojDinions  are  entitled  to  the  greatest  respect. 
One  word  more: — "Usually  the  whole  albuminous  con- 
stituents of  our  food  are  so  transformed  in  the  stomach, 
intestines,  and  liver,  that  no  albuminous  substances  of  the 
kind,  which  can  pass  through  the  kidneys  get  into  the 
general  circulation.  But  if  one  takes  such  a  quantity  of 
eggs  as  to  comj^letely  overtask  the  digestive  powers,  the 
egg-albumen  will  pass  unchanged  into  the  blood  and  be 
excreted  by  the  kidneys.  Other  albuminous  substances, 
the  products   of  intestinal  digestion,   and  peptones   also, 


224  LIVER  DISTURBANCE.  [chap.  xi. 

occasionally  make  their  appearance  in   the  urine  as  egg- 
albumen  "  (Lauder  Brunton). 

From  what  has  been  said  above,  it  will  be  abundantly 
clear  to  the  reader  that  the  perversions  of  the  metabolism 
of  albuminoids  in  the  liver,  are  verv  interestino-  in  relation 
to  the  presence  of  lithic  acid  and  lithates,  of  excess  of  urea, 
and  even  of  crude  albumen  in  the  urine.  All,  separate  or 
combined,  may  be  so  produced,  without  kidney  disease 
necessarily  being  present;  or  even  being  the  consequential 
result  for  a  very  considerable  time.  (1.)  Crude  albumen 
may  pass  unchanged  in  the  liver  into  the  general  circula- 
tion, and  pass  out  by  the  kidneys.  (2.)  The  metabolism 
may  take  the  direction  of  an  excess  of  urea.  Or  (3)  the 
splitting  up  of  albuminoids  may  result  in  the  production 
of  a  large  quantity  of  lithic  acid,  usually  in  combination 
with  ammonia  or  soda.  Such  conditions  may  be  tem- 
porary, as  the  result  of  *' acute  liver-indigestion;"  or 
they  may  be  less  pronounced  but  permanent,  and  then 
in  the  language  of  Geo.  Johnson,  "  renal  degeneration  is  a 
consequence  of  the  long -continued  elimination  of  products 
offaidty  digestion,  through  the  kidney s.'^'^ 

,  Such  then  is  the  production  of  lithiasis.  But  in  the 
full  consideration  of  this  subject,  we  must  include  the 
disturbances  which  this  "  waste-laden"  blood  produces  in 
its  wake.  In  Part  II.  the  matter  of  consequential  renal 
changes  will  be  discussed  at  length;  together  with  the 
changes  in  the  heart,  arteries,  and  other  organs,  i.e.,  the 
phenomena  of  gout,  or  lithiasis.  Here  it  will  be  sufficient 
to  review  the  symptoms  and  disturbances  which  belong 
to  acute  conditions  of  liathiasis,  or  lithfemia  (Murchison's 


CH.\r.  XI.]  LIVER  DISTURBANCE.  225 

term),  provoked  by  '' liver-indigestion; "  or  perversion  of 
metabolism  in  the  latter  portion  of  the  digestive  act,  as 
seen  in  persons  "who  are  not  the  subjects  of  confimicd 
gout. 

Asthma. — This  is  one  of  the  outcomes  of  nitrogenised 
waste  being  present  in  excess  in  the  blood;  especially 
nocturnal  asthma.  This  is  not  to  be  confounded  with 
the  asthma  which  is  set  np  by  some  irritation  with  swell- 
ing of  the  bronchial  lining  membrane,  often  the  result  of 
a  cold.  It  comes  on  suddenly  in  sleep,  after  a  late  meal. 
Dr.  Todd  thouD-ht  that  there  was  a  Qnateries  morhi  which 
acted  through  the  pneumogastrics  upon  the  respiratory 
centre  in  the  medulla.  Dr.  H^'de  Salter  was  of  opinion 
that  the  attack  was  set  up  by  "  the  actual  presence  in  the 
vessels  of  the  lungs  of  the  materials  taken  up  from  the 
stomach  and  intestines."  He  pointed  out  how  an  attack 
provoked  by  a  full  meal  taken  late  in  the  day,  could  be 
averted;  if  the  sufferer  would  sit  up  instead  of  going  to  bed 
until  the  hour  of  attack  was  passed.  By  so  doing,  the  res- 
piratory centre  could  better  and  more  successfully  resist 
the  irritation  set  up  by  the  irritant  material.  The  fact 
that  if  a  certain  hour  or  period  could  be  so  passed,  the 
attack  did  not  come  on,  is  suggestive.  It  was  not  post- 
poned; it  was  averted.  Awake,  the  poison  was  inopera- 
tive; asleep,  it  certainly  set  up  an  asthmatic  paroxysm. 
This  certainly  connects  it  with  the  latter  portio-n  of  the  di- 
gestive act;  while  its  association  with  a  full  meal  renders 
its  connection  with  the  digestive  act  all  the  more  certain. 
Dr.  Murchison  says: — "Asthma,  like  gout,  is  an  here- 
ditary disease;  it  is  common  among  persons  springing 
10* 


22G  LIVER  DISTURBANCE.  [chap.  xi. 

from  a  gouty  stock;  it  is  not  unfrequently  associated  with 
gout,  gall-stones,  or  other  hepatic  derangements  in  the 
same  individual;  and  attacks  of  asthma  have  been  known 
to  alternate  periodically  with  attacks  of  gout.  Moreover, 
an  asthmatic  paroxysm,  like  an  attack  of  gout,  of  vertigo, 
or  of  sleeplessness,  is  often  excited  by  a  fit  of  indigestion, 
and  by  the  use  of  particular  articles  of  diet." 

They  are  related  to  those  attacks  of  what  Basham  called 
**  inexplicable  dyspnoea,"  found  in  the  subjects  of  chronic 
gouty  kidneys.  It  may,  however,  be  questioned  whether 
any  irritation  is  conveyed  up  the  pneumogastric  nerves 
to  the  medulla, — an  hypothesis  which  has  been  violently 
stretched  to  explain  a  variety  of  respiratory  affections;  but 
rather  by  a  direct  action  of  the  products  of  abnormal 
digestion  in  the  blood,  upon  the  respiratory  centre.  At 
other  times,  bronchitis  seems  to  be  induced;  while  chronic 
bronchitis  is  a  very  common  occurrence  in  chronic  gout; 
at  times,  not  unfrequently,  an  attack  of  acute  bronchitis 
takes  the  place  of  a  gouty  paroxysm. 

Disturbances  i7i  the  Heart  are  very  common.  There  is 
palpitation,  which  is  not  that  form  excited  by  gas  in  the 
stomach,  or  transverse  colon,  pressing  up  the  thin  dia- 
phragm against  the  heart,  and  by  its  "elastic  pressure" 
interfering  with  the  heart's  movements;  a  well-known 
form  of  palpitation.  The  palpitation  of  lith£emia  is  not 
always  felt  along  with  flatulence,  but  irregularly,  as  re- 
gards its  connection  with  meals.  It  is  casually  linked 
with  imperfect  assimilation  and  evidences  of  waste  in  the 
blood,  with  a  high  arterial  tension,  and,  at  times,  with  an 
ill-fed  or  half-starved  heart;  and  its  origin  is  the  same  as 


CHAP.  XI.]  LIVER  DISTURBANCE.  227 

that  of  the  imperfect  angina  pectoris  vaso-motoria,  to  be 
spoken  of  a  little  later  on.  Then  there  is  irregularity  in 
the  heart's  action,  allied  to  that  spoken  of  in  p.  190,  in 
which  the  heart's  action  is  depressed:  in  other  cases  there 
is  irregularity  in  the  volume  as  well  as  the  rhythm  of  the 
pulse;  or  there  may  be  intermissions,  with  or  without 
fluttering  of  the  heart's  action.  In  others,  again,  there 
is  pulsation  of  the  abdominal  aorta.  Dr.  Baillie  drew  at- 
tention to  this  subject  long  ago,  in  a  paper  entitled  "Upon 
a  Stronw'  Pulsation  of  the  Aorta  in  the  Episfastric  Re- 
gion,"  and  Sir  Charles  Scudamore  in  his  work  on  "  Gout 
and  Gravel,  and  General  Observations  on  Morbid  States 
of  the  Digestive  Organs,"  4th  Edit.,  1823,  wrote:— "The 
pulsation  in  the  epigastric  region,  which  is  sometimes  felt 
to  an  alarming  degree,  by  dyspeptic  persons,  is  seldom  met 
with  in  persons  who  are  subject  to  acute  gout."  It  is 
frequently  found  during  the  time  of  the  digestive  act, 
mostly  in  persons  of  a  highly  developed  nervous  system; 
and  is  unaccompanied  by  any  severe  disturbance  of  the 
general  health.  "The  undue  pulsation  in  these  cases  is 
often  subdued  by  treatment  directed  against  the  liver " 
(Murchison). 

Angina  Pectoris. — This  is  quite  a  common  malady  with 
those  who  suffer  from  "  liver  indigestion,"  and  is  not  un- 
frequently  met  with  in  the  sons  of  fathers  who  have  died 
of  anmna;  and  who  may  themselves  die  of  ang-ina  in 
advanced  life,  when  their  heart-walls  become  the  seat  of 
fatty  degeneration.  From  the  researches  and  observations 
of  Eulenberg,  Nothnagel,  Lauder  Brunton  and  others,  we 
have  learned  that  angina  pectoris  is  not  a  neuralgia  of  the 


228  LIVJSR  DISTURBANCE.  [chap.  xi. 

heart,  as  thought  by  Heberden  and  those  who  have  fol- 
lowed him,  so  frequently  as  a  vaso-motor  affection.  It  is 
due  to  spasm  of  the  small  arteries,  excited  by  the  irritant 
presence  of  nitrogenised  waste  in  the  blood  in  excess.  This 
causes  a  high  blood-pressure  in  the  arteries  which  may 
provoke  an  attack  of  palpitation,  or  of  angina  pectoris 
vaso-motoria,  as  the  case  may  be.  As  chronic  states, 
hypertrophy  of  the  left  ventricle  and  atheroma  of  the 
arteries  are  set  up  by  this  sjDasm.  When  the  gouty  heart 
passes  into  the  stage  of  failing  hypertrophy  from  fatty  de- 
generation, these  attacks  become  very  serious.  The  rotten 
h-eart-walls  fail,  and  angina  is  as  grave  then,  as  it  is  com- 
paratively free  from  danger  while  the  heart-walls  are  struc- 
turally sound.  If  the  reader  wishes  to  pursue  this  matter 
further,  he  will  find  it  discussed  in  a  chapter  of  its  own,  in 
my  work  On  the  Heart  and  its  Diseases  (2nd  edit.,  1879). 

The  tendency  to  arteriole  spasm  is  evidenced  by  the 
hands  "dying"  at  times,  or  the  feet  being  painfully  cold 
in  the  subjects  of  lithiasis. 

The  tendency  of  vitiated  states  of  the  blood,  when  laden 
with  lithic  acid  and  lithates,  to  produce  inflammation  of  the 
veins,  is  recognised  by  Sir  James  Paget  ("  On  Gouty  and 
some  other  Forms  of  Phlebitis").  It  is,  however,  rather 
found  in  acute  paroxysms  in  those  who  suffer  from  gout. 
When  the  urine  is  laden  with  these  products  of  perverted 
metabolism,  it  possesses  irritant  qualities.  Gouty  urethritis 
simulating  gonorrhoea,  is  no  rare  affection:  or  chordee,  or 
even  orchitis  may  be  so  excited.  Stone  in  the  kidne}^  or 
bladder  is  often  found  in  persons  generally  well,  entailing 
their  own  symptoms:  or  as  Dr.  Bennett  writes — "I  have 


CHAP.  XI.]  LIVER  DISTURBANCE.  229 

met  with  some  patients  so  extremely  sensitive  in  tliis  re- 
spect that  even  in  health,  if  the  ingestion  of  food  is  fol- 
lowed by  the  formation  of  lithates,  they  become  aware  of 
their  presence  as  soon  as  the  urine  reaches  the  bladder, 
owing  to  the  sudden  pain  they  occasion.  I  have  attended 
many  patients  suiTering  from  irritable  bladder  from  this 
cause,  who  have  been  erroneously  thought  to  labour  under 
stone,  stricture  of  the  urethra,  or  inflammation  of  the  neck 
of  the  bladder."  He  says  that  fibrinous  casts  of  the  kidney 
tubules  are  sometimes  found.  "Their  presence  is  gener- 
ally considered  to  indicate  severe  irritation  or  even  disease 
of  the  kidney.  Mere  fibrinous  casts,  however,  not  contain- 
ing oil  corpuscles  or  epithelial  casts,  are  constantly  present 
in  simple  cases  of  dyspepsia,  in  which  the  kidneys  are  evi- 
dently neither  the  seat  of  great  irritation,  nor  of  actual 
disease."  He  concludes — "  When  morbid  deposits  in  the 
urine,  the  result  of  defective  nutrition,  are  thus  the  cause 
of  irritability  of  the  urinary  organs,  it  is  vain  to  hope  for 
relief  until  the  digestive  functions  have  been  restored  to  a 
more  healthy  state,  and  until  the  urine  has  ceased  to  be 
loaded  with  the  lithatic  salts.  The  latter  keep  up  constant 
irritation  in  the  bladder  and  urinary  passages,  in  the  same 
way  as  sand  constantly  thrown  into  the  eye  would  keep  up, 
irritation  or  inflammation  of  the  conjunctiva." 

Lithic  acid  teases  the  whole  urinary  tract  from  the  tu- 
bules of  the  kidney,  which  are  not  rarely  found  blocked 
with  small  calculi  of  lithic  acid,  to  the  meatus  itself.  This 
irritant  urine  often  excites  pruritus  vulvae,  or  even  an  ecze- 
matous. condition  of  the  genitals.  Such  is  the  direct  effect 
of  the  presence  of  lithic  acid. 


230  LIVER  DISTURBANCE.  [chap.  xi. 


Skin  Affections  are  common:  and  pruritus  ani,  with  or 
without  eczema,  is  sadly  common  in  liver-indigestion. 
General  pruritus,  or  itching,  is  found  in  jaundice,  or  in 
lithsemia,  and  is  an  outcome  of  blood-poisoning  by  the 
products  of  indigestion.  Urticaria  is  so  associated;  as  is 
eczema,  some  other  skin  affections,  and  also  boils  and 
carbuncles.  Diabetes  is  also  accompanied  by  phlegmonous 
or  carbuncular  inflammations.    A  suggestive  relationship  ! 

Nervous  Symptoms. — Upon  no  tissue  does  the  lithic  acid 
exert  a  more  irritant  influence  than  upon  the  brain  cells, 
and  of  this  the  most  prominent  is  disturbance  of  temper. 
The  most  constant  symptom,  in  my  mind,  is  irritability  of 
temper,  in  conditions  of  lith^mia.  Even  naturally  good 
tempered  persons  get  cross,  irritable,  peevish,  and  waspish, 
when  their  blood  is  so  poisoned.  With  some  who  are  in- 
dolent, this  toxaemia  may  spur  them  into  activity,  if  the 
blood  is  at  the  same  time  well-fed;  and  these  are  usually 
stout,  well-nourished  persons.  But  in  others,  where  the 
brain  is  ill-fed,  as  well  as  poisoned  by  lithates,  the  results 
are  far  from  pleasing.  In  the  first  edition  of  my  work  On 
the  Diseases  of  the  Heart  (1872)  is  written—"  It  would  often 
be  satisfactory  and  agreeable  to  explain  anomalous  and 
•indefensible  acts  by  this  theory,  and  to  lay  some  of  human 
frailty  to  the  charge  of  uric  acid."  To  this  is  appended 
a  foot-note,  evidently  inspired  by  some  recent  experiences, 
the  memory  of  which  yet  remains  sharply  defined.  "  It 
may  seem  somewhat  out  of  place  to  allude  to  impressions 
formed  by  the  writer  as  to  the  effect  of  retained  urine  salts 
on  mental  processes  here,  even  in  a  foot-note;  but  this 
excess  of  urine  salts  docs  seem  to  have  a  stimulant  effect 


CHAP.  XI.]  LIVER  DISTURBANCE.  231 

upon  the  -brain,  and  gouty  people  are  usually  possessed  of 
some  talent.  The  conclusions,  so  far,  seem  to  indicate 
that  nuiny  persons  of  good  brains,  but  lacking  in  energy 
and  inclination  to  think,  are  stimulated  by  retained  uric 
acid  into  excellent  thinking,  and  attain  a  reputation  late  in 
life.  While  in  others,  with  small,  irritable,  '  foxy  '  brains, 
the  disturbins:  effect  of  these  retained  excreta  makes  the 
cares  of  business,  etc.,  quite  intolerable.  Retirement  from 
business  at  first  gives  relief;  but  soon  this  irritability  ex- 
cites them  to  have  something  to  do,  and  this  too  commonly 
is  effected  by  becoming  members  of  boards  and  committees, 
when  this  mental  irritability  takes  the  form  of  mischievous 
perversity,  of  ill-controlled  interference  Avith  everything 
and  everybody.  In  this  condition  they  remind  the  writer 
of  nothing  so  much  as  a  cancerous  gland — no  longer  ful- 
filling any  useful  purpose,  but  merely  a  source  of  irritation 
to  everything  around  them,"  A  further  experience  only 
endorses  this  opinion:  and  such  persons  are  *' social  nui- 
sances;" they  "  cannot  agree  with  themselves,"  and  of 
course,  it  is  needless  to  say,  they  cannot  agree  with  any- 
body else.  A  relative  of  the  writer  used  to  say  that  "  she 
felt  as  if  she  could  fight  with  a  feather,"  when  her  brain  was 
teased  with  these  lithates.  Irritability  of  temper  is  pro- 
nounced, and  little  things  put  the  sufferer  out  to  an  extent 
quite  disproportionate  to  the  exciting  cause;  while  the  posi- 
tive mental  suffering  and  annoyance  is  aggravated  by  the 
consciousness  that  there  is  unreasonableness  in  it,  a  some- 
thing wrong  within  themselves.  Often  there  is  a  sleepless 
night,  the  patient  not  getting  off  to  sleep  till  late  in  the 
morning  ;  he,  or  she,  aAvakes   not   feeling  refreshed,  but 


232  LIVER  DISTURBANCE.  [chap.  xi. 

irritable  and  cross  to  a  degree;  ready  to  take  offence  at 
anything  or  nothing  at  times,  the  dread  of  the  household 
if  in  authority.  If  the  head  of  a  business  firm,  the  under- 
lings are  apt  to  have  a  bad  time  of  it;  for  however  reason- 
able and  considerate  ordinarily,  at  these  times  he  is  simply 
unbearable. 

The  ordinary  explanation  "  he  got  out  of  the  wrong  side 
of  the  bed  "  is  strictly  applicable  to  these  cases.  Minutise 
are  criticised  or  quarrelled  with,  and  the  objections  raised 
certainly  come  often  under  the  heading  *'  frivolous  and 
vexatious."  Nor  is  it  only  others  who  have  to  suffer;  the 
subjective  sensations  of  the  individual  are  far  from  envi- 
able. They  know  they  are  misbehaving  themselves,  yet 
cannot  exercise  sufficient  inhibition  to  control  their  morbid 
impulses.  There  is  irritability  blended  with  depression; 
that  is  the  mental  attitude.  Life  is  a  discord,  not  a  musical 
note  !  Yet  they  do  not  receive  the  sympathy  and  con- 
sideration fairly  due  to  them.  When  the  cripple  halts  in 
his  walk,  we  do  not  blame  him,  we  readily  recognize  his 
maimed  condition ;  but  when  individuals  manifest  impaired 
mental  action,  instead  of  recognising  an  infirmity  we  at  once 
accuse  them  of  "  giving  way  to  their  temper,"  or  "  not 
exercising  proper  self-control,"  or  in  some  other  recog- 
nised phrase  blame  them  morally.  But  to  do  so  is  to  act 
without  rational  self-control  on  our  own  part.  Perhaps 
they  exercise  all  the  control  in  their  power;  only  it  is  un- 
equal to  completely  subduing  the  irascibility  excited  by 
the  toxic  matters  in  the  blood  circulating  in  the  brain. 
They  often  merit  a  consideration  and  a  sympathy  which  is 
not  exhibited  towards  them  by  most  persons.     They  have 


CHAP.  XI.]  LIVER  DISTURBANCE.  233 


claims  to  our  charity,  much  stronger  than  they  get  credit 
for. 

The  causes  of  such  Functional  Derangement  of  the 
Liver,  may  now  be  considered  by  the  liglit  of  what  has 
been  said  before. 

It  is  quite  clear  that  first  and  foremost  stands  an  ex- 
cess of  albuminoid  food.  About  this  there  can  exist  no 
scintilla  of  doubt,  or  question.  When  albuminoid  food  is 
taken  in  excess  of  the  tissue  needs,  the  surplusage,  or 
luxus  consumption,  is  split  up  in  the  liver;  and  it  is 
in  this  function  of  the  liver  we  find  the  disturbance 
which  leads  to  the  excessive  production  of  lithic  acid  and 
lithates.  It  is  not  necessary  to  review  the  subject  again 
here,  but,  to  speak  broadly,  instead  of  urea  we  find  the 
liver  producing  the  less  oxidised  and  less  soluble  uric,  or 
lithic  acid.  There  is  a  vicious  habit  formed  which  tends  to 
perpetuate  itself.  The  vice  persists,  until  the  gouty  habit, 
or  cachexia  is  ena^endered:  and  then  this  condition  of  the 
production  of  lithic  by  perverted  metabolism  in  the  liver  is 
riveted  on  to  it.  Not  only  then  must  albuminoids  be  given 
in  sparing  quantities,  but  it  does  not  seem  a  matter  of  in- 
difference which  form  of  albuminoid  material  is  taken  as 
food.  Clinical  observations  tend  to  point  in  the  direction 
of  the  avoidance  of  meat-albuminoids;  especially  the  flesh 
of  beasts,  as  compared  with  that  of  birds  and  fishes. 
While  caseine  seems  indicated  as  the  form  least  liable  to  be 
split  up  into  lithic  acid;  either  as  milk,  the  well  recog- 
nised milk  dietary;  or  as  the  vegetable  legume,  of  which 
Revalenta  Arabica  is  the  best  known  type.  We  are  not  as 
yet  in  a  position  to  be  very  dogmatic  on  this  subject,  but 


234  LIVER  DISTURBANCE.  [chap.  xi. 

such  conclusion  seems  suggested;  like  the  shadow  of  the 
comino-  reality  projected  forward,  in  front  of  it.  But  to 
this  we  will  revert  in  the  next  chapter.  Here  the  great 
matter  to  insist  upon  is  the  avoidance  of  the  too  free 
indulo-ence  in  the  toothsome  and  palatable  albuminoids, 
especially  flesh. 

The  next  matter  is  a  sufficiency  of  oxygen,  which  in- 
volves fresh  air  and  exercise.  The  liver-indigestion  of  the 
city-man  is  often  the  consequence  of  an  insufficiency  of 
oxygen  to  expedite  the  metabolism  and  splitting  up  of  al- 
buminoids in  the  liver.  The  amount  taken  as  food  and  di- 
gested by  the  gastric  juice  and  trypsin  of  the  pancreas  may 
not  be  excessive;  but  from  want  of  a  sufficiency  of  oxygen 
the  liver  cannot  deal  efficiently  with  the  proteids  borne  to  it 
in  the  blood  of  the  portal  vein.  Consequently  we  find  the 
products  of  suboxidation,  to  use  the  language  of  the  late 
Bence  Jones,  formed  instead  of  the  normal  urea.  The 
air  of  many  business  places  is  not  calculated  to  provide  the 
active  oxygen  required  for  the  oxidation  of  albuminoids. 
The  improvement  which  follows  upon  a  day  or  two  in  the 
country  tells  at  once  its  own  tale,  as  to  what  is  requisite 
in  this  class  of  case. 

Long  ago  Mr.  Alexander  Shaw  pointed  out  {Medical 
Times  and  Gazette,  July  and  September,  1842)  how  the 
movements  of  the  diaphragm  facilitate  the  flow  of  blood 
through  the  liver,  brought  to  it  by  the  valveless  portal  vein. 
A  deep  inspiration  sucks  the  blood  into  the  liver,  while  ex- 
piration expels  it  with  a  jet.  Exercise,  especially  horse- 
back exercise,  that  time-honoured  remedy,  is  then  indica- 
ted in  these  cases  of  liver-indigestion  due  to  an  imperfect 


CH,ip.  XI.]  LIVER  DISTURBANCE  235 

supply  of  oxygen.  In  all  cases  where  there  is  a  tendency 
to  the  formation  of  the  vicious  habit  of  the  production  of 
lithic  acid  in  excess,  in  persons  much  confined  indoors  in 
ill-ventilated  chambers,  it  is  desirable  that  fresh  air  in  the 
country,  aud  best  by  the  sea-side,  should  be  obtained  if 
possible. 

The  deficiency  of  oxygen  in  tropical  temperatures  has  a 
marked  effect  in  the  production  of  the  bilious  maladies, 
the  disorders  of  the  liver,  so  commonly  seen  in  returned 
East  Indians.  Xo  doubt  their  indulgence  in  animal  food 
has  much  to  do  with  it.  Those  races  who  live  on  rice  and 
dahl  (a  legume)  or  other  of  the  legunilnosce  suffer  little  from 
biliarj^  derangement.  Experimentation  has  corroborated' 
this  view  founded  upon  clinical  observation,  extending  over 
centuries;  and  animals  which  are  exposed  to  a  high  temper- 
ature are  found  to  have  degenerative  changes  instituted  in 
their  livers.  This  is  a  division  of  the  subject  which  recom- 
mends itself  to  those  who  meditate  a  residence  in  tropical 
climates. 

Then  there  is  no  doubt  about  the  effect  of  alcohol  in  pro- 
ducino-  liver  derano-ement.  We  all  know  how  enlaro-ement 
of  the  liver,  followed  by  subsequent  contraction,  is  induced 
bvthe  abuse  of  alcohol.  About  this  no  one  entertains  any 
doubt.  But  alcohol  taken  even  sparingly  disagrees  with 
some  persons  whose  livers  are  easily  upset,  and  they  have 
scrupulously  to  avoid  it;  for  it  is,  indeed,  a  poison  to 
them.  Even  the  form  of  alcohol  is  not  unimportant.  "With 
one  a  glass  of  champagne,  with  another  a  single  glass  of 
port  is  sufficient  to  upset  the  liver;  and  a  recurring  ex- 
perience tells  unmistakably  the  relations  being  those  of 


236  LIVER  DISTURBANCE.  [chap.  xi. 

cause  and  effect,  and  not  mere  coincidence.  To  speak 
broadly,  it  would  seem  that  alcohol  stimulates  the  liver  to 
give  off  some  of  its  stored  glycogen,  and  thus  unlocks  a 
quantity  of  heat-giving  material,  possibly,  perhaps  prob- 
ably, by  increasing  the  amount  of  blood  in  the  hepatic 
artery,  a  recognised  cause  of  the  liberation  of  glycogen 
or  animal  starch;  and  its  conversion  by  the  hepatic  fer- 
ment into  suo-ar.  This  is  in  accordance  with  the  fact  tliat 
a  glass  of  wine,  or  its  equivalent,  will  often  excite  a  glow 
and  a  feelino'  of  warmth,  not  commensurate  with  the  heat- 
producing  capacity  of  the  mere  hydrocarbon  of  the  alcohol 
itself.  When  the  habit  of  taking  alcohol  to  excess  ha? 
been  formed,  and  especially  taking  it  in  large  quantitie:? 
on  an  empty  stomach,  the  liver  begins  to  enlarge;  and 
soon  a  quantity  of  pathological  connective  tissue  is  formed, 
which  gives  it  greater  firmness  and  density  of  texture;  at 
the  same  time,  its  functional  capacity  is  impaired,  espe- 
cially its  power  of  dealing  with  albuminoids,  as  seen  by 
the  presence  of  lithates  in  the  urine.  The  subjective 
phenomena  of  indigestion  are  commonly  seen  in  drunk- 
ards. The  addition  of  alcohol  to  a  dietary  rich  in  all 
material,  especially  albuminoids,  is  a  fertile  factor  in  the 
production  of  liver  indigestion;  and  of  all  the  alcoholic 
beverages,  those  prepared  from  malt  act  most  jDotentlyfor 
evil. 

Before  proceeding  to  discuss  two  matters  of  great,  in- 
deed, cardinal  importance,  in  this  perverted  metabolism 
in  the  liver,  which  leads  to  the  production  of  lithic  acid 
in  abnormal  quantities,  it  may  be  well  to  say  a  few  words 
on  some  other  factors. 


CHAP.  XL]  LIVER  DISTURBA:S''CE.  237 


Disease  of  the  heart,  and  to  a  lesser  extent  disease  of  the 
lungs,  may  lead  to  embarrassment  of  the  liver  functionally, 
by  gorging  it  with  venous  blood;  as  a  consequence  of  the 
Q-ackwirkung,  or  "  back-working,"  from  the  obstruction  of- 
fered to  the  blood  flow.  When  there  is  such  a  lesion  as 
impedes  the  flow  of  blood  through  the  lungs,  the  right 
ventricle  becomes  enlarged,  and  so  the  driving  power  is 
increased. 

But  the  enlargement  usually  entails  a  certain  amount  of 
reo-urgitation  through  the  tricuspid  valve,  and  then  the 
veins  from  the  liver  become  enlarged,  and  the  flow  through 
the  liver  is  obstructed.  The  liver  becomes  enlarged  in 
turn,  and  can  be  felt  to  pulsate  with  the  impact  of  the 
venous  blood  driven  backward  through  the  insufficient  tri- 
cuspid valve,  each  time  the  big  right  ventricle  strikes.  This 
"  liver  pulsation  "  is  often  a  diagnostic  sign  of  the  greatest 
value  in  certain  cases.  The  liver  so  engorged  with  this 
regurgating  venous  blood,  is  embarrassed,  maimed,  or 
crippled  in  its  functional  w^orking,  and  a  free  production 
of  lithates  is  the  consequence.  In  the  consideration  of 
this  matter  it  must  not  be  forgotten  that,  whether  disease 
of  heart  or  lung,  the  oxidizing  processes  are  impaired  by 
defective  chemical  interchanges  in  the  thorax  ;  and  so  a 
deficiency  of  oxygen  is  an  operating  factor  not  to  be 
overlooked. 

Then  all  structural  disease  of  the  liver  mutilates  the 
organ  and  limits  its  functional  capacity.  When  an  abscess 
of  the  liver  has  destroyed  a  great  portion  of  the  viscus, 
it  leaves  the  remainder  scarcely  equal  to  the  demand  upon 
it.     This  is  seen  by  the  diminution  in  the  amount  of  urea 


238  LIVER  DISTURBANCE.  [chap.  xi. 

formed  when  the  liver  is  the  seat  of  extensive  disease. 
Dr.  Parkes  found  in  examining  the  urine  of  cases  of  liver- 
disease  from  India,  the  amount  of  urea  varied  greatly. 
When  the  injury  was  extensive,  so  as  to  have  destroyed 
a  large  area  of  the  liver  structure,  the  amount  was  less- 
ened in  a  degree  in  strict  proportion  to  the  extent  of  the 
destruction  worked  :  while  in  other  cases,  when  there  w^as 
no  destruction  of  the  liver  structure  but  engorgement  of 
it  with  blood,  increasing  the  activity  of  the  liver-cells, 
the  amount  of  urea  was  increased,  as  was  also  that  of 
lithic  acid.  In  acute  yellow  atrophy  the  amount  of  urea 
is  largely  decreased,  while  that  of  leucin  and  tyrosin  is 
largely  increased.  In  cirrhosis  also,  the  amount  of  urea  is 
diminished;  and  the  same  occurs  in  cancer  of  the  liver, 
as  seen  in  cases  quoted  by  several  authorities.  When  the 
structure  of  the  liver  is  destroyed,  its  functional  power  is 
lessened  in  a  corresponding  degree.  Consequently,  the 
causes  which  derange  the  liver  usually  are  specially  oper- 
ative upon  persons  whose  livers  are  the  seat  of  structural 
change. 

Derangements  of  the  liver  may  be  consequent  upon 
primary  and  preceding  disorder  of  the  gastric  or  intes- 
tinal organs  of  digestion.  Crude,  or  abnormal,  or  partially 
digested  matters,  absorbed  into  the  blood  of  the  portal  vein 
from  the  alimentary  canal,  may,  in  the  course  of  time,  lead 
to  secondary  disorder  of  the  liver.  This,  however,  it  must 
be  admitted,  is  founded  a  good  deal  on  <^  j^Hor/  reasoning; 
and  though  the  features  of  cases  often  suggest  this,  it 
can  scarcely  be  regarded  as  demonstrated  to  a  conviction. 

There  remain  two  matters   connected  with    functional 


OHAP.  XL]  LIVER  DISTURBANCE.  239 

dcrang-ement  of  the  liver,  still  to  be  considered,  of  the 
greatest  interest.  Tlie  one  is  the  effect  of  nervous  in- 
fluences; and  the  other  is  that  of  what  may  be  termed 
congenital  insufficiency  in  the  liver. 

As  to  nervous  influences  they  have  been  very  fully  con- 
sidered in  Chap,  vi.,  pp.  86-109.  It  Avas  there  pointed  out 
that  mental  disturbance  exercises  a  profound  influence 
over  the  digestive  organs,  and  very  specially  the  liver. 
The  extent  to  which  such  influence  affects  the  liver  is 
almost  inconceivable,  until  the  literature  of  the  subject  is 
examined.  For  centuries  we  have  been  more  or  less  famil- 
iar with  the  effects  of  indigestion  and  mal-nutrition  upon 
the  brain  and  nervous  system:  but  the  converse,  the  effect 
of  nervous  disturbance  upon  the  liver  and  alimentary 
canal,  is  one  wath  which  our  acquaintance  is  more  recent. 
Dr.  Murchison  sums  up  the  matter  very  completely  and 
tersely,  and  as  his  views  wdll  give  corroboration  to  wdiat 
I  have  written  elsewhere,  I  will  give  them  verbatim. 
"  Many  facts  show  the  great  influence  of  the  nervous 
system  upon  the  secreting  organs.  Sudden  fear,  or  other 
severe  mental  emotion,  has  been  known  to  arrest  the  se- 
cretion of  milk  and  saliva;  and  we  have  already  seen  how 
injuries  and  diseases  of  nerve-tissue  may  jDroduce  diabetes 
by  deranging  the  glycogenous  function  of  the  liver.  But 
many  other  ailments  of  the  liver  besides  diabetes  have  a 
nervous  orio-in.  Prolono^ed  mental  anxiety,  worry,  and  in- 
cessant  mental  exertion,  not  only  interfere  with  the  j^ roper 
secretion  of  bile,  but  too  often  derange  the  processes  of 
sang-uification  and  blood-change,  in  which  the  liver  is  so 
deeply  concerned,  and  induce  lith^emia,  with  many  of  the 


240  LIVER  DISTURBANCE.  [chap.  xi. 

symptoms  already  described.  Gravel  and  g-out  are  ac- 
knowledged to  be  the  frequent  lot  of  those  who  live  more 
by  nerve-  than  by  muscle-work.  Such  results  are  all  the 
more  likely  to  ensue  if  the  diet  has  been  such  as  favours 
hepatic  derangement — if,  for  example,  to  drown  grief,  the 
patient  has  indulged  in  stimulants — and  the  habits  have 
been  sedentary.  There  is  also  good  evidence  that  nervous 
agencies  may  not  only  cause  functional  derangement,  but 
even  structural  disease,  of  the  liver.  Acute  atrophy,  in 
which  the  secreting  cells  are  rapidly  disintegrated,  and  the 
functions  of  the  organ  arrested,  appears  in  many  instances 
to  have  a  purely  nervous  origin;  very  of  ten  the  first  symp- 
toms of  the  disease  have  occurred  immediately  after  a 
severe  fright,  or  an  outburst  of  passion,  in  a  person  pre- 
viously healthy.  An  impression  made  upon  the  brain 
appears  to  be  reflected  to  the  liver  and  deranges  its  nutri- 
tion. Many  observations  have  satisfied  me  that  the  extru- 
sion of  gall-stones  from  the  gall-bladder,  as  well  as  their 
formation,  may  be  traced  to  nervous  agency.  Dr.  Budd 
has  also  observed  that  mental  anxiety  or  trouble  has 
great  influence  in  the  production  of  gall-stones;  and  I 
have  repeatedly  known  attacks  of  biliary  colic  from  gall- 
stones, excited  by  some  sudden  emotion.  Lastly*  even 
cancer  of  the  liver  appears  sometimes  to  result  from  the 
functional  derangement  induced  in  the  first  instance  by 
mental  trouble.  I  have  been  surprised  at  the  frequency 
with  which  patients  suffering  from  primary  cancer  of  the 
liver  have  traced  the  commencement  of  their  ill-health  to 
indigestion,  following  protracted  grief  or  anxiety.  The 
cases  have  been  far  too  numerous  to  be  accounted  for  on 


CHAP.  XI.]  LIVER  DISTURBANCE.  24=1 

the  supposition  that  the  mental  distress  and  the  cancer 
have  been  mere  coincidences.  A  similar  observation  has, 
I  believe,  been  made  by  Sir  Robert  Christison,  and  by 
other  eminent  authorities."  These  are  very  definite  and 
equally  strong  and  decided  expressions  of  opinion. 

Dr.  Budd  wrote  :  ("  Diseases  of  the  Liver,"  3rd  edit., 
1857). — "Another  condition  that  seems  to  me  to  have 
great  influence  on  the  production  of  .gall-stones,  or  at 
least  of  biliary  gravel,  is  mental  anxiety  or  trouble." 

It  is  indeed  abundantly  shewn  that  mental  disquietude 
disturbs  the  functions  of  the  liver,  one  and  all,  "  stock, 
lock,  and  barrel;"  and,  not  only  that,  but  may  set  up  even 
structural  disease,  to  the  extent  of  cancer  itself. 

"  Congenital  Insufficiency  "  of  the  liver  is,  there  is  every 
reason  to  believe,  the  cause  of  much  of  the  trouble  to 
which  *'  bilious  "  persons  are  liable.  Dr.  Budd,  a  keen 
observer,  one  of  a  laro-e  familv  of  medical  men,  all  of 
whom  were  remarkable  for  their  acumen  and  their  incisive 
thought,  expressed  himself  on  this  subject  as  follows: — 

"  In  most  persons,  perhaps,  a  portion  of  the  liver  may 
waste  or  become  less  active,  without  sensible  derangement 
of  health.  They  have  more  liver,  as  they  have  more  lung, 
than  is. absolutely  necessary.  In  others,  on  the  contrar}^, 
the  liver,  from  natural  conformation,  seems  only  just  capa- 
ble of  effecting  its  purpose  in  favorable  circumstances. 
They  are  born  with  a  tendency  to  bilious  derangements. 
This  innate  defect  of  power  in  the  liver  has  its  counterpart 
in  the  deficient  respiratory  power  in  persons  with  vesicular 
emphysema  of  the  lungs,  and,  like  the  latter  defect,  and 

most  other  peculiarities  of  physical  structure,  is  no  doubt 
11 


242  LIV:ER  disturbance.  [chap.  xi. 

frequently  inherited.  Persons  who  inherit  this  feebleness 
of  the  liver,  if  we  may  so  term  it,  or  in  whom,  in  conse- 
quence of  disease,  a  portion  of  the  liver  has  atrophied, 
or  the  secreting  element  of  the  liver  has  been  damaged, 
may  suffer  little  inconvenience  as  long  as  they  are  placed 
in  favorable  circumstances,  and  observe  those  rules  which 
such  a  condition  requires;  but  whenever  from  any  cause — - 
as  a  hot  climate,  gross  living,  indolent  habits,  constipation, 
— a  more  abundant  secretion  of  bile  is  requisite  to  purify 
tlie  blood,  the  liver  is  inadequate  to  its  office,  and  they 
become  bilious  and  sallow."  Such  then  is  a  very  shrewd 
observation,  and  explicit  expression  of  opinion,  in  one  of 
our  most  trustworthy  authorities;  none  the  less  deserving 
of  confidence  because  he  used  the  phraseology  of  his  day; 
and  did  not  know  that  the  liver  was  largely  engaged  with 
the  albuminoid  material  of  our  food.  Had  he  been  aware 
of  this,  he  would  have  employed  a  more  comprehensive 
expression  than  that  of  "a  more  abundant  secretion  of 
bile  is  requisite  to  purify  the  blood."  He  would  have 
grasped  the  subject  more  efficiently,  as  Dr.  Murchison, 
possessed  of  more  recent  and  more  extended  knowledge, 
has  done.  He  quotes  Dr.  Budd,  and  adds: — "The  person 
is  born  with  a  tendency  to  biliary  derangements.  Gout 
and  diabetes,  which  we  have  found  to  originate  in  hepatic 
derangement,  are  hereditary  diseases  ;  and  the  liver  is 
always  very  readily  disordered  in  persons  who  inherit  a 
tendency  to  gout.  This  constitutional  tendency  to  hepatic 
derangement,  is  too  often  lost  sight  of  by  patients,  and  per-- 
baps  sometimes  by  their  medical  advisers.  The  habitual 
use  of  alcohol  is  often  recommended  for  various  ailments. 


CHAP.  XI.]  LIVER  DISTURBANCE.  243 

Avitliout  due  regard  to  the  tendency  of  the  individual  to 
liepatic  derangement,  and  thus  serious  consequences  may 
ultimately  arise  from  alcohol  taken  with  a  medicinal  object. 
Again,  a  patient  often  argues  that  his  liver-troubles  can- 
not be  due  to  what  he  eats  or  drinks,  because  he  is  most 
careful  as  compared  with  friends  who  indulge  largely  and 
suffer  nothing-,  for2:ettin2-  the  ada^re:  'one  man's  food  is 
another  man's  poison.'  One  man,  for  instance,  may  drink 
a  bottle  of  wine  and  be  none  the  worse,  whereas,  another 
has  his  liver  derano-ed  bv  a  sino-le  g-lass."  Doubtless  the 
explanation  offered  above  is  a  reasonable  one,  and  tells  us 
fairly  satisfactorily  Avhy  one  man  cannot  eat  and  drink 
without  suffering  for  it,  what  would  be  quite  a  moderate 
amount  for  another  person;  who  can  habitually  take  that 
much,  and  more,  without  any  inconvenience  supervening 
thereupon. 

The  subject  has  not  escaped  the  observation  of  other 
authorities  and  Dr.  J.  Henry  Bennett  writes : — ''  The 
gouty  diathesis,  when  it  is  the  result  of  hereditarj^  taint, 
has  proved  in  my  experience  the  cause  of  some  of  the 
most  intractable  forms  of  d\'spepsia,  both  in  male  and 
female,  that  I  have  met  with.  Indeed,  I  believe  that 
dyspepsia,  recognising  this  cause,  is  in  some  instances, 
quite  incurable,  and  can  only  be  palliated.  It  is  a  sad 
legacy  that  the  gout}^,  from  self-indulgence,  often  leave  to 
their  children,  even  when  they  themselves  are  free  from  it. 
Singularly  enough,  it  does  not  show  itself,  necessarily,  in 
all  the  children  of  a  gouty  father  or  mother,  but  only 
in  one  or  more  of  the  number.  The  children  of  gouty 
parents  ought,  more  especially,  to  follow  the  hygienic  and 


244  LIVER  DISTURBANCE.  [chap.  xi. 

dietetic  laws  laid  down  in  these  pages,  if  they  wish  to  es- 
cape much  suffering'.  As  a  rule,  they  ought  to  be  all  but 
water-drinkers,  throughout  life;  they  have  to  pay  the  pen- 
alty of  their  progenitor's  excesses,  or  dietetic  errors.  If 
the  gouty  diathesis  is  strongly  marked,  they  should  be 
most  moderate  and  abstemious  in  their  food  habits,  and 
lead  as  active  and  muscular  a  life  as  possible.  Indeed, 
they  should  never  lose  sight  of  the  fact,  that  a  miserable 
gouty  old  age  may  be  their  fate,  should  their  life  be  pro- 
longed, unless  they  make  many  sacrifices  to  ward  off  the 
impending  danger."  This  relation  of  indigestion  with  the 
gouty  diathesis,  i.e.,  a  constitution  which  is  gouty  by  in- 
heritance, is  one  which  is  the  more  extensively  recognised, 
as  the  subject  is  more  investigated.  There  is  a  well- 
known  story  which  may  be  quoted  in  proof  thereof.  An 
old  clergyman  once  ejaculated,  "I  have  been  a  dyspeptic 
for  fifty  years.  Thank  God,  for  it !  "  The  reason  of  his 
satisfaction,  expressed  so  devoutly,  was  the  fact  that  all 
his  brothers  were  dead  and  buried,  cut  off  by  gouty 
affections;  he  alone  remained  of  the  family.  Dyspepsia 
had  saved  him  from  the  fate  which  overtook  the  rest.  The 
dyspeptic  then  is,  under  certain  circumstances,  a  better  life, 
in  insurance  phrase,  than  those  who  are  free  therefrom. 
But  is  longevity  worth  the  price,  many  will  be  tempted  to 
ask  ? 

Dr.  Leared  commences  his  little  work  "  On  Imperfect 
Digestion,"  as  follows: — "The  digestive  power  may  be 
compared  to  the  physical  strength.  Every  individual  can, 
without  inconvenience,  carry  a  certain  weight,  while  any 
addition  to  it  is  accompanied  by  a  proportionate  sense  of 


CHAP.  XI.]  LIVER  DISTURBANCE.  245 


oppression.     In  the  same  way,  what  is  called  indigestion, 
is  often  simply  a  result  of  excess.     The  amount  of  food 
which  each  man  is  capable  of  digesting  with  ease  has  al- 
ways a  limit."     Quoting  Cicero's  gratitude   that  his  ad- 
vancing years  had  diminished  his  inclination  to  eat  and 
drink,  he  points  out  that: — "At  all  stao-es  of  adult  life, 
but  particularly  during  its  decline,  the  appetite  is  over- 
stimulated  by  condiments,  and  tempted  to  excess  by  culi- 
nary refinements.     Dyspepsia  is  not  the   worst  result  of 
this.       Gout,  and  still  more  serious    maladies    connected 
with  an   impure  state  of   the  blood,  closely    follow.     In- 
fringements of  the  laws  of  digestion  are  constantly,  and 
in   many   cases  unconsciously,  committed.     One  man    di- 
gests with  ease  an  amount  of  food,  which  would  be  fatal 
to  another.     Animal   food  is  easily  digested  by  some  per- 
sons twice  or  even  three  times  daily;  while,  if  taken  by 
others   more   than    once,  it    is    sure    to    induce    suffering. 
Nevertheless,  the    diet  of  persons  associated  together  is 
apt  to  be  the  same,  and  sufficient  individuality  in  matters 
of  eating  and  drinking  is  seldom  observed." 

There  is  much  force  in  the  way  in  which  Dr.  Leared 
here  points  out  the  diversity  of  individuals  in  their  diges- 
tive capacity,  like  any  other  capacity;  and  also  that  the 
power  is  not  always  the  same  in  the  same  individual,  but 
is  diminished  with  age.  That  we  are  apt  to  eat  alike, 
w^hatever  our  individual  capacities,  is  certain;  and  the 
dyspeptic  who  moves  much  in  society,  or  "goes  out  at 
all "  is  always  being  tempted,  inveigled,  or  goaded  by 
jeers  and  jibes,  into  eating  a  great  deal  infinitely  better 
avoided;    with  the  person  who  suffers   from  "  liver-insuf- 


246  LIVER  DISTURBANCE.  [chap.  xi. 

ficiency,"  any  indiscretion  is  swiftly  punished,  and  suffer- 
ing follows  closely  on  the  heels  of  the  offence. 

This  congenital  incapacity  in  the  liver  deserves  an  at- 
tention it  does  not  receive  either  from  the  patients  who  suf- 
fer, or  the  medical  men  who  advise  them,  as  a  rule.  Just 
as  we  see  poor  wretches  with  flat  narrow  chests,  and  we 
recognise  that  in  consequence  of  their  badly  developed 
chests  they  will  readily  succumb  to  disease  of  the  respira- 
tory organs;  because  at  the  best  they  only  possess  as  much 
lung  as  will  barely  carry  them  on  in  a  makeshift  way.  So 
we  should  learn  to  recognise  the  other  fact, — that  of  the 
congenitally  incompetent  liver.  If  such  recognition  were 
more  general  it  would  be  well  for  those  so  born  imperfect. 
They  must  eat  in  proportion  to  the  capacity,  or  rather  the 
want  of  it,  in  their  livers;  not  according  to  their  appetite 
or  the  habits  of  society,  if  they  wish  to  exist  in  (compara- 
tive) comfort.  I  remember  well  a  gentleman  of  good 
descent,  in  my  early  experience  in  Westmoreland  when  I 
took  my  father's  practice,  who  was  embarrassed  by  one  of 
these  incapable  livers.  Straitness  of  means  and  a  waxing 
family  compelled  him  to  live  very  sparingly  and  economi- 
cally; and  partly  by  that,  partly  by  long  hours  every  day 
in  the  open  air,  in  the  garden,  or  on  the  roads  with  a  rake, 
a  life  of  industry  comparing  favourably  with  that  of  many 
field-hands,  he  managed  to  keep  himself  in  health  and 
comfort.  But  the  slightest  omission  or  relaxation  of  his 
dietetic  or  hygienic  arrangements  was  followed  by  retribu- 
tion, swift  and  sufficient  to  keep  him  at  his  round  of  self- 
denial  and  self-imposed  toil  for  a  considerable  time  to  come 
afterwards;    and  occasionally,  but  rarely  in  fact,  he  went 


CHAP.  XT.]  LIVER   DISTURBANCE.  247 

away  to  visit  a  more  afiluent  brother  for  a  week,  with  the 
invariable  result  of  well-marked  articular  gout  being  estab- 
lished in  him.  For  many  long  years  this  went  on,  and 
this  poor  gentleman  taught  me  much  about  congenital  im- 
pairment of  the  assimilative  organs.  Probably  this  is  a 
well-marked  instance,  a  very  well  defined  instance  indeed, 
of  the  influence  of  descent  in  impairing  the  digestive  pro- 
cesses. The  plebeian  alderman  eats  (or  is  reputed  to  do 
so),  vigorously  with  undiminished  zest  and  appetite,  free 
from  gout  or  dyspepsia,  into  good  old  age;  giving  the  lie 
to  the  statement  that  "  of  all  carnal  pleasures  cometh 
satiety  at  the  last.''  While  the  well  descended  gentleman 
gets  gout  on  the  slightest  provocation;  eats  as  daintily  as 
a  lady,  when  his  means  will  permit  it,  drinks  most  abstemi- 
ously, and  yet  his  enemy  has  him  on  the  slightest  provoca- 
tion. There  must  be  a  reason  for  this,  surely  !  And  prob- 
ably the  explanation  lies,  as  Dr.  Budd  wisely  suggested, 
in  some  congenital  impairment  in  the  functional  capacity 
of  the  liver.  The  fact  that  the  children  of  the  alderman 
who  could  perform  such  gastronomic  feats,  do  not  possess 
their  progenitor's  capacity,  is  one  well  recognised.  Indeed 
it  is  simply  impossible  to  avoid  the  conclusion,  that  there 
exists  a  section  of  society  who  are  hereditarily  feeble  in 
the  liver,  either  actually  bilious  by  bile-acids,  or  the  sub- 
ject of  lithiasis,  from  the  liver  being  unequal  to  the  nor- 
mal transformations  of  albuminoids.  Such  persons  step 
into  their  inheritance,  whether  they  like  it  or  not.  Some 
persons  inherit  unstable  nervous  systems,  others  weak 
lungs,  while  indubitably  others  inherit  incapable  livers  ; 
and  the  sooner  the  fact  of  "  liver-insufnciency,"  is  gener- 


248  LIVER  DISTURBANCE.  [chap.  xi. 

ally  recognised,  the  better  for  those  who  suffer  (potentially) 
therefrom. 

After  this  rather  lengthy  consideration  of  "  Biliousness  " 
and  "Liver  Indigestion,"  we  can  approach  all  the  more 
satisfactorily  the  subject  of  the  treatment  of  these  allied 
conditions;  and  comprehend  all  the  more  clearly  the  why 
and  wherefore  of  what  will  be  recommended  in  the  ensu- 
ing chapter. 


CHAPTER  XII. 

THE    TREATMENT    OF    LIVER    DISTURBANCE 
—MEDICINAL   AND  DIETETIC. 

The  reader  will  now  be  fully  prepared  to  enter  upon  the 
question  of  how  to  improve  the  condition  of  persons  who 
labour  under  hepatic  derangement.  For  a  certain  class  of 
readers  this  section  of  the  subject  will  possess  little  interest, 
and  a  languid  curiosity  is  all  it  will  arouse.  But  I  venture 
to  think  there  is  a  much  larger  class  who  will  eagerly  read 
this  chapter;  viz.,  that  portion  of  the  medical  profession 
who  not  only  are  sincerely  desirous  of  doing  what  good 
they  can  to  their  fellow  creatures;  but  who  feel  that  they 
would  be  glad  to  give  their  patients  something  like  "  value 
received  "  for  their  money.  A  valid  excuse  may  be  ten- 
dered for  simply  watching  a  case  of  uncomplicated  pneu- 
monia, or  typhoid  fever,  running  its  course;  prepared  to 
take  the  requisite  active  steps  when  the  necessity  for  them 
arises.  But  such  mere  observation  of  cases  of  derange- 
ment of  the  liver  is  what  no  one  would  attempt  in  the  pos- 
session of  his  reasoning  faculties,  be  the  same  more  or  less; 
and  if  it  were  essayed,  the  patient  would  soon  express  his 
opinion  on  the  subject — and  emphatically,  I  suspect. 

And  in  doing  so  he  would  be  held  justified  by  all:  when 
we  think  how  important  it  is  that  a  man  be  enabled  to 
work  in  comfort,  or  an  approach  to  it;  and  not  only  that, 
but  also  to  have  his  health  as  long  as  possible.  We  all 
know  how,  as  age  advances,  the  digestiv^e  and  assimilative 
11* 


250  LIVER  DISTURBANCE.  [chap.  xn. 

organs  begin  to  fail.  Gout  is  a  disease  of  middle  age  and 
advanced  life.  The  work  which  the  liver  has  to  do  day  by 
day  tells  upon  it,  and  instead  of  the  ordinary  normal  meta- 
bolism in  it,  disturbances  and  perversions  arise.  The 
arrangements  which  change  grape-sugar  into  glycogen, 
and  glycogen  back  again  into  grape-sugar,  become  dis- 
turbed, and  then  diabetes  is  the  consequence.  Or  the 
splitting  up  of  albuminoids  is  perverted,  and  then  lithic 
acid  is  largely  formed,  instead  and  in  lieu  of  urea,  and 
then  gout  is  the  result.  Now  it  behooves  the  medical  man 
to  keep  well  in  view  the  future,  as  well  as  to  recognise  the 
present  necessities,  in  cases  of  liver  derangement.  It  is 
not  only  desirable  to  give  relief  at  the  time;  but  it  is  well 
to  include  the  future  in  the  therapeutic  scheme.  It  is  not 
only  the  immediate  trouble  of  the  patient,  it  is  what  is 
looming  in  the  distance  which  must  be  calculated  for  in 
the  estimate.  This  factor  it  was,  which,  being  omitted 
from  the  calculation,  ultimately  brought  such  discredit  on 
the  "  blue-pill  and  black-draught  "  treatment.  Such  means 
gave  immediate  relief;  about  that  there  can  exist  no  ques- 
tion. But  what  was  the  consequence  ?  Possessing  a  ready 
means  of  procuring  relief,  our  predecessors  went  on  their 
way  rejoicing — ate,  drank  and  were  merry,  as  in  the  day 
before  the  flood,  "  and  knew  not  till  the  flood  came  and 
swept  them  all  away."  So  it  was  with  them.  They  set 
no  bounds  to  their  indulgence,  and  fell  back  on  the  blue- 
pill  and  black-draught  when  inclined,  until  an  unremedi- 
able  condition  was  established.  Instead  of  righting  itself, 
the  system  became  accustomed  to  this  artificial  means  of 
restoring  the  equilibrium,  until  the  power  of  self-restoration 


CHAr.  xn.]  LIVER  DISTURBANCE.  251 

of  the  balance  became  irretrievably  lost;  and  then  a  per- 
manent cachexia  settled  down  upon  the  remainder  of  their 
days.  So  conspicuous  did  the  evil  become,  that  the  stream 
set  in  in  the  opposite  direction  so  effectually  that  now  many 
persons,  yes,  and  many  medical  men  too,  look  upon  a  mer- 
curial pill  as  if  it  were  "  possessed  of  a  devil."  The  reaction 
came  and  swept  reason  away  in  its  current  as  it  often  does; 
and  one  extreme  begat  the.  other.  I  remember  well,  not 
many  months  ago,  reading  a  paper  before  a  large  suburban 
society  upon  the  desirability  of  sweeping  the  accumulated 
nitrogenised  waste  out  of  the  blood,  in  certain  cases  of 
dilated  heart  with  enlarged  liver;  when,  in  the  discussion 
which  followed,  several  gentlemen  of  various  ages  asked  if 
I  thought  a  mercurial  at  times  permissible  in  such  cases; 
as  timidly  as  if  they  felt  themselves  liable  to  be  suspected 
of  wishing  to  resuscitate  the  Druidical  faith,  or  exhibiting 
a  latent  belief  in  the  old  notion  that  "  nine  live  lice  upon  a 
piece  of  bread  and  butter"  were  the  most  appropriate  and 
effectual  treatment  of  an  attack  of  jaundice.  And  on  as- 
suring them  that  I  not  only  thought  such  remedial  agent 
permissible  and  lawful,  but  even  approved  thereof,  they 
seemed  immensely  relieved ;  while  several  and  sundry 
others  present  interchanged  a  significant  glance  as  if  they 
thought  I  was  the  subject  of  incipient  general  paralysis; 
indicating,  too,  that  my  utterances  in  future  would  receive 
no  regard  or  confidence  from  them.  They  clearly  would 
have  none  of  this  renewal  of  an  exploded  doctrine;  they 
would  as  soon  think  of  reverting  to  the  Pythagorean  teach- 
ing of  the  transmigration  of  souls.  But,  perhaps,  they  will 
find  after  a  while  that  a  mercurial  pill,  succeeded  by  a 


252  LIVER  BISTURBANCK  [chap.  xn. 

smart  purgative,  is  a  very  good  plan  of  treatment  in  certain 
cases;  provided  that  they  follow  it  up  by  a  rational  dietary, 
so  as  to  prevent  future  accumulation  of  waste  matter  in 
the  blood. 

It  was  the  nes:lect  of  this  latter  which  brouo-ht  the  mer- 
curial  remedy  into  disrepute.  By  attention  to  it  in  the 
future,  the  mercurial  pill,  followed  by  a  saline  laxative  will 
have  its  day  again;  liable,  however,  to  be  again  discarded 
if  abused  !  Colchicumhas  been  in  and  out  of  the  Pharma- 
copoeia some  half-dozen  times  at  least,  according  to  the 
ebb  and  flow  of  medical  belief,  and  the  fashion  of  the  times. 
Unbounded  faith  is  often  the  precursor  of  an  equally  blind, 
irrational  unbelief,  as  history  tells  us.  Such  oscillations  of 
belief  simulate  at  first  the  overthrow  of  a  superstition,  and 
bv  some  are  thousfht  to  be  such  a  movement,  until  time 
disproves  it.  The  trying  for  witchcraft,  and  the  general 
belief  in  witches,  their  wholesale  detection  and  cruel  pun- 
ishment, culminated  in  a  reaction  as  swift  as  it  was  com- 
plete; and  the  belief  of  one  generation  was  the  scoff  and 
scorn  of  the  next  immediately  succeeding  it.  Sir  Thomas 
Browne,  the  renowned  author  of  Heligio  Medici,  believed 
in  witches,  and  once  as  a  witness  swore  in  court  ''that  ho 
was  clearly  of  opinion  that  the  persons  were  bewitched." 
Yet  the  men  who  believed  in  witches  and  the  judicial  pun- 
ishment of  witchcraft  were,  as  Lecky  points  out,  quite  as 
capable  of  forming  an  accurate  opinion  on  other  matters  of 
life  as  other  people  have  been.  So  the  men  who  practised 
medicine  with  the  use  of  the  blue-pill  and  black-draught 
were  in  the  possession  of  their  senses;  only  abuse  led  to 
reaction.     Now  the  dread  and  horror  of  a  mercurial  in  any 


CH.1P.  xn.]  LIVER  DISTURBANCE.  253 

case,  and  under  all  circumstances,  is  leading  a  large  section 
of  men  to  the  opposite  extreme — of  its  avoidance  in  season 
and  out  of  season;  and  that  portion  of  my  audience  looked 
upon  me  as  if  I  were  a  nineteenth  century  would-be  imita-- 
tor  of  Julian  ''the  apostate."  The  heroic  plan  of  treatment, 
the  lancet  and  the  blue  pill,  has  been  followed  by  a  re- 
action which  has  extended  to  Nihilism  with  many  as  regards 
drugs;  while  an  unbounded  faith  in  beef-tea,  and  the  sus- 
taining plan  of  treatment  now  generally  obtains  with  them. 
Nevertheless,  in  many  cases  a  mercurial  and  a  saline  after- 
wards form  a  very  good  plan  of  therapeutic  attack  in  emer- 
gencies. Admitting,  at  the  same  time,  that  the  natural 
loss  of  appetite  leading  to  abstinence,  is  much  better  in 
many  cases.  Nor  does  this  confession  of  faith  in  mercuri- 
als as  a  cholagogue  involve  a  retrograde  movement  which 
will  extend  to  a  resuscitation  of  a  belief  in  witchcraft,  or 
the  tenets  of  Druidism.  To  advocate  the  proper  use  of 
mercury  as  a  cholagogue  is  not,  then,  the  revival  of  an 
exploded  superstition.  Still  it  is  now  acknowledged  that 
it  is  not  well  to  resort  to  the  habitual  use  of  mercury  as  a 
cholagogue;  for  it  is  found  that  once  accustomed  thereto, 
the  liver  does  not  respond  to  other  less  potent  stimulants; 
like  the  toper  who,  familiar  with  brandy  and  a  split  seltzer, 
^lares  little  for  a  drau^-ht  of  hock  and  soda-water. 

The  subject  will  be  reverted  to  a  little  further  on. 

But  our  choice  of  remedial  agents  should  be  pro- 
foundly influenced  by  the  fact  that  as  age  proceeds,  the 
assimilating  organs  lose  some  of  their  pristine  energy. 
Nor  does  the  mature  organism  require  the  material  which 
is  essential  to  the  building  of  the  tissues  in  growth,  and  in 


254:  LIVER  DISTURBANCE.  [chap.  xn. 

that  consolidation  of  the  system  which  follows  growth  of 
stature.  The  energy  of  manhood  will  enable  the  system  to 
burn  up  much  food,  perhaps  not  absolutely  demanded,  but 
which  is,  at  least,  not  harmful.  But  when  advancing 
years  limit  the  energies,  then  such  consumption  becomes 
baneful;  while  a  less  liberal  supply  of  oxygen  renders  the 
task  of  oxidizino-  albuminoids  more  difficult  than  it  once 
was.  A  natural  failure  of  the  appetite  follows  ;  which 
should  be  respected,  and  not  struggled  with.  There  is 
then,  in  the  first  place,  w^hat  to  avoid;  when  this  spontane- 
ous anorexia,  or  loss  of  appetite  manifests  itself — its  lesson 
is  to  leave  it  alone:  lessened  body-wants  no  longer  require 
an  active,  keen  appetite;  and  attempts  to  whip  up  the  appe- 
tite by  bitters  are  to  be  discouraged.  The  appetites  vary 
with  advancing  years.  The  mistress  gives  way  to  the  cook; 
and  the  skill  of  the  latter,  like  the  charms  of  the  former, 
is  frausrht  with  an  element  of  dano-er  to  the  owner.  The 
temptations  to  eat  more  than  either  is  required  or  good 
for  him,  to  which  the  middle-aged  man  of  means  is  ex- 
posed, the  natural  weakness  or  lack  of  strength  to  resist 
temptation,  should  induce  him,  if  reason  ruled  the  roost, 
to  discharge  his  cook  for  one  of  less,  instead  of  more  skill, 
when  the  natural  decay  of  the  appetite  begins  to  manifest 
itself.  Such,  however,  is  not  the  case,  and  is  not  likely  to 
be  the  case  for  a  long  time  to  come.  So  the  cook,  the 
more  skilful  the  more  dangerous,  is  the  first  matter  to  be 
decided.  He  or  she  must,  or  ought  to  be,  discharged  ;  or 
handed  over  to  the  possessor  of  a  more  youthful  appetite 
and  vigorous  set  of  digestive  organs.  Then  the  family 
medical  attendant  should  pledge  himself,  by  solemn  oath 


CHAT,  xn.]  LIVER  DISTURBANCE.  255 

and  covenant,  never  to  prescribe  bitters  when  the  appetite 
is  defective,  or  capricious;  the  patient  equally  binding  him- 
self never  to  whip  or  flog  the  jaded  appetite  by  bitters,  either 
hop  bitters  or  Angostura  with  a  little  gin,  or  dry  sherry 
before  dinner.  If  such  compact  were  made  and  kept  faith- 
fully, many  a  liver  would  be  able  to  hold  its  own,  and  fulfil 
its  function  fairly  well,  which,  under  the  present  arrange- 
ment, is  prematurely  worn  out  years  before  its  potential 
exhaustion.  It  is  but  human  to  sacrifice  the  future  to  the 
present;  and  an  ajDpetite  which  is  waning  ought  to  be 
conserved,  its  owner  thinks!  Certainly;  the  question  is 
how  best  can  it  be  conserved  ?  It  is  not  preserved  by 
stimulating  the  appetite  and  the  stomach  to  consume  more 
food  than  the  liver  can  dispose  of.  Rather  the  judicious 
plan  is  to  follow  the  indications  of  the  appetite,  and  when 
it  flags  to  eat  accordingly.  But  whether  this  plan  Avill 
obtain,  or  not,  till  the  millennium  is  reached,  is  a  subject 
which  cannot  be  settled  out  of  hand.  It  may  safely  be 
said,  that  it  ought  to  obtain. 

Especially  should  such  rule  be  observed  by  persons  Avho 
have  resided  in  tropical  climates,  or  been  the  subject  of 
hepatic  disorders.  Dr.  Budd  makes  a  remark  which  may 
profitably  be  quoted  here,  viz.: — "In  persons  Avho  die 
of  yellow  fever,  the  liver  presents  various  morbid  appear- 
ances, which  have  been  minutely  described  by  Louis,  that 
depend  not  on  the  products  of  inflammation,  or  on  the 
state  of  the  vessels,  but  on  the  condition  of  the  cells.  The 
damage  done  to  the  liver  in  this  way  may  last  for  years. 
It  is  probable  that  the  bilious  disorders  of  many  men  on 
their  return  to  this  country  from  India,  and  other  hot  cli- 


256  LIVER  BISTURBANCE.  [chap.  xn. 

mates,  are,  in  great  measure,  owing  to  permanent  injury 
done  to  the  secreting  element  of  the  liver."  This  remark 
is  pregnant  with  suggestiveness,  that  in  many  cases  the 
secreting  cells  of  the  liver,  by  which  the  metabolism  and 
splitting  up  of  albuminoids  by  oxidation  are  carried  on, 
become  impaired  functionally;  if  not  always  structurally. 
Such  modifications  should  be  remembered  when  the  pa- 
tient's dietary  is  being  laid  down:  nor  need  such  consid- 
eration be  restricted  to  returned  East  Indians;  it  might 
quite  well  be  extended  to  those  who,  though  they  may 
not  have  resided  in  tropical  countries,  nevertheless  have 
suffered  from  biliary  and  hepatic  disturbances. 

It  may  be  well  to  proceed  to  the  consideration  of  acute 
bilious  congestion  of  the  liver.  In  such  cases  in  children, 
it  may  be  well  to  administer  an  emetic  of  ipecacuanha, 
with  a  small  dose  of  a  mercurial,  followed  by  a  purgative. 
But  this  should  not  be  resorted  to  habitually  in  consequence 
of  unrestricted  indulgence  in  food.  It  should  only  be  a 
dernier  resort  in  emergencies.  Very  often  the  loss  of  ap- 
petite and  languor  lead  to  spontaneous  restoration  of  the 
health;  and,  even  at  the  risk  of  shocking  some  anxious 
mothers,  or  impulsive  practitioners,  it  may  be  said  that 
such  is,  with  delicate  children,  much  better  for  them  in 
every  way;  educating  the  system  to  take  care  of  itself,  and 
proving  a  very  good  lesson  for  future  guidance.  Still,  the 
emetic  and  purgative  may,  at  times,  be  indicated. 

In  acute  cono-estion  of  the  liver  of  warm  climates,  I 
may  quote  Sir  Joseph  Fayrer,  K.C.S.I.,  F.R.S.L.  and  E., 
written  for  me  for  my  Practitioner^ s  IlandhooJc  of  Treat- 
ment:— "In  reference  to  the  treatment  of  the  functional 


CHAP,  xn.]  LIVER  DISTURBANCE.  257 


derangements  of  the   liver  which   arise  from  cono-estion 
and  I  think   more   especially  that   form  in  which  it  is  ac- 
companied  by   anaemia,  such   a  condition,   in  short,  as  is 
so  frequently  seen  in  persons  who  have  lived  long  in  hot 
malarious  climates   like   India,  the  West  Indies,  and  the 
Coast  of  Africa,  I  may  say  this.     Bevond  mere  swellino- 
of  the  liver  from  engorgement  with  blood,  other  chancres 
— fatty  or  amyloid— will  no    doubt  supervene,    and  it  is 
often  difficult  to  determine  how  far  the  functional  is  due 
to  the  structural  change.     The  treatment  I  generally  find 
most   effective,    is   attention   to   diet   and   drinks.     Avoid 
much  fatt}',  sugary,  and  alcoholic  fluids.     No  beer.     Claret 
and  water  for  drink.     Warm  clothing,  so  as  to  keep  the 
skin  moist.      An  occasional  dose  of  colocynth  and  calomel, 
or  blue  pill,  and  every  morning,  or  every  other  mornino-, 
a  dose  of  saline  aperient,  such    as   sulphate   of  magnesia, 
with  quinine  and  gentian,  sufficient   each  time  to  produce 
two  or  three  loose  motions.      Counter-irritation  by  tincture 
of  iodine  over  the   loins.      WJieJi  the  portal  circulation  is 
relieved,  some  preparation    of   iron  may    be  very  useful. 
The  urine  is  a  good  test  of  the  hepatic   condition;  it  will 
improve  under  the  above  treatment,  but  it  is  well  to  give 
the  patient  some  alkaline  waters — Vichy,  Vals,  or  Carlsbad. 
Albuminuria  will  be  present  at  times,,  when  the  kidneys, 
like  other  abdominal  viscera,  are  congested,  or  are  irritated 
by  lithic  acid.     In  my  opinion,  too  much  importance  is  at- 
tached to  this  symptom  in  some  cases.     Indeed,  I  think 
the  subject  of  albuminuria  would  bear  rewritino-.     Albu- 
minuria  may  be  functional  in    such  cases,  and  pass  away 
like  the   other  symptoms."     Certainly,  looked  at  by  our 


258  LIVER  DISTURBANCE.  [chap.  xn. 

most  recent  light,  such  albuminuria  may  be  but  a  part 
of  tlie  hepatic  derangement,  and  pass  away  with  it  ac- 
cordingly. Now  is  it  unfriendly  criticism  of  Sir  Joseph 
Fayrer's  practice  to  say,  that  in  his  line  of  treatment,  the 
matter  of  albuminoids  is  omitted  ?  Yet  to  withhold  them 
is  in  all  probability  also  very  desirable,  and  would  be  ac- 
companied by  improvement  in  the  symptoms.  The  patient 
should  be  kept  upon  rice-water,  or  other  simple  starchy 
matter,  which  gives  the  liver  the  least  labour.  Or  a  little 
beef-tea  with  baked  flour  in  some  form  might  be  taken 
sparingly;  where  procurable,  a  milk  dietary  might  be 
substituted,  or  whey,  where  there  is  anorexia  with  much 
thirst.  Probably  a  liberal  supply  of  subacid  fruit  is  ahvays 
desirable,  as  well  as  grateful  to  the  patient. 

As  regards  permanent  biliousness  as  seen  in  England, 
my  practice  has  been  modified  by  the  light  of  advancing 
phj'^siology,  with  advantage,  I  firmly  believe,  to  my  pa- 
tients. I  no  longer  allow  them  to  consume  albuminoids 
in  any  quantity;  but  instruct  them  in  this,  as  in  other 
elements  of  their  food.  But  this  is  the  dietetic  manage- 
ment to  be  discussed  further  on. 

It  is  well  to  give  them  a  pill  containing  a  hepatic  stimu- 
lant, to  be  followed  by  a  mineral  saline  next  morning 
Two  copious  motions,  one  before,  the  other  after  breakfast, 
furnish  much  sense  of  comfort  in  cases  where  the  bowels 
are  sluggish;  that  is  in  the  bulk  of  cases.  By  such  treat- 
ment, they  are  greatly  improved;  even  in  cases  where  "  con- 
genital insufficiency  of  the  liver  "  is  presumably  present. 

At  this  point  it  may  be  well  to  review  those  medicinal 
agents  which  act  upon  the  liver. 


CHAT,  xn.]  LIVER  DISTURBANCE.  259 

Soda,  and  its  salts,  are  found  to  act  potently  upon 
the  liver.  Consequently,  while  sulphate  of  magnesia  is 
a  capital  purgative  when  the  intestinal  glands  alone  re- 
quire stimulating,  this  salt  acts  little  if  at  all  upon  the 
liver;  and  when  it  is  desirable  to  "rouse  the  liver,"  as 
the  phrase  runs,  sulphate  of  soda,  its  bitter  taste  not- 
withstanding, should  be  prescribed.  The  experiments  of 
Rutherford  countenance  and  corroborate  the  conclusions 
at  which  clinical  empiricism  had  arrived.  Potash  for  the 
kidneys;  ammonia  for  the  lungs;  soda  for  the  liver:  these 
are  the  bases  of  the  salts  to  be  used  according-  to  the  cir- 
curastances  of  cases.  Sulphate  of  soda  is  best  taken  in  the 
mornino;  first  thing-  on  o-etting-  out  of  bed.  Then  some 
bicarbonate  of  soda,  or  Rochelle  salts,  must  be  added; 
with  a  carminative  of  some  kind,  in  a  bitter  infusion, 
warm.  Such  a  draught,  first  thing,  is  of  the  greatest 
service. 

The  carminative  not  only  covers  the  objectionable  taste 
of  the  salts,  but  is  itself  useful.  Dr.  Budd  wrote: — "  Pep- 
per, ginger,  and  other  hot  spices,  are  also  supposed,  and 
perhaps  justly,  to  render  the  liver  more  active,  and  increase 
the  secretion  of  bile."  It  is  well  to  bear  this  in  mind, 
in  prescribing  for  hepatic  derangements  under  all  circum- 
stances. 

Chloride  of  ammonium  has  always  had  warm  advocates 
for  its  utility  as  a  cholagogue. 

Mercury,  in  all  its  forms  and  preparations,  has  been  in 
use  for  centuries  in  liver  deranorements.  Sad  and  disas- 
trous  are  the  consequences  of  the  abuse  of  this  powerful 
medicine.     The  indiscriminate    and   inordinate    resort  to 


260  LIVER  DISTURBANCE.  [chap.  xn. 

mercury  has  brought  the  treatment  of  the  Services  into 
well-deserved  disrepute.  Potent  for  good,  still  more  po- 
tent for  evil,  when  abused;  mercur}^  has  fallen  from  its 
hio-h  estate  into  comparative  disgrace,  or  neglect.  Its 
claims,  however,  must  be  considered  rationally.  Highly 
as  it  was  once  extolled,  it  is  now  equally  abused,  and  de- 
preciated. Nor  can  we  wonder  at  this,  when  we  think 
how  it  has  come  about  !  The  terrible  consequences  of  the 
administration  of  mercury  till  free  salivation  was  produced, 
formed  a  lesson  which  many  took  to  heart;  in  some  cases 
too  earnestly.  The  zealots  who  ordered  patients  to  be 
S8.1ivated  to  so  many  pints  a  day,  simply  dethroned  their 
idol  in  public  opinion.  Then  followed  the  quack-salvers, 
with  their  patent  medicines,  who  announced,  with  all  the 
flourish  of  trumpets  at  their  command,  that  their  pills 
*'  contained  no  mercury."  The  action  actually  extended 
to  the  point  of  abandoning  mercury  in  the  treatment  of 
syphilis.  Slowly  the  tide  of  indignation  against  the  use 
of  mercury  has  ebbed  until  its  use  in  syphilis  is  once  more 
universal. 

The  late  Prof.  John  Hughes  Bennett  hated  mercury 
with  a  virulence  scarcely  conceivable  by  those  who  did 
not  know  him.  He  denounced  it,  he  inveighed  against  it, 
he  poured  all  the  power  of  ridicule  he  possessed,  and  that 
was  no  slight  amount,  upon  it;  he  shot  every  arrow  of 
sarcasm  in  his  quiver  and  it  was  a  pretty  full  one,  at  the 
misguided,  wicked  persons  who  dared  to  advocate  the 
administration  of  a  single  grain  of  calomel.  Peace  to  his 
ashes;  an  iconoclast,  he  did  a  good  service  in  his  way. 
Still  the  crusader  is  an  enthusiast;  and  an  enthusiast  is 


CHAP,  xn.]  LIVER  DISTURBANCE.  261 

not  a  person  of  a  judicial  frame  of  mind.  The  crusade 
against  mercury  is  now  passing-  away;  liaving  played  a 
useful  part;  the  tendency  at  present  is  the  other  way,  and 
the  cautious  and  rational  use  of  mercury  is  once  more 
finding  numerous  advocates.  In  speaking  of  mercury  Dr. 
Budd  wrote: — "The  marked  temporary  benefit  often  re- 
sulting^ from  mercurv  o-iven  for  this  effect  has,  from  the 
difficulty  of  distinguishing  the  various  diseases  of  the  liver, 
and  the  constant  indiscriminate  use  of  the  drug,  led  to 
great  evils.  This  medicine  was  at  one  time,  by  English 
practitioners,  given  almost  indiscriminately,  and  long  per- 
severed in,  for  disorders  of  digestion,  many  of  which  did  not 
depend  on  fault  of  the  liver  at  all,  but  on  local  disease  of 
the  stomach  or  intestines,  or  on  faulty  assimilation,  the 
result  of  debility,  which  the  prolonged  use  of  the  mercury 
but  too  often  increased."  This  is  a  judicial  expression  of 
opinion  by  a  man  whose  opinion  is  entitled  to  every  re- 
spect. The  way  in  which  German  writers  have  condemned 
the  English  use  of  mercury  has  done  much  to  help  on 
the  growing  disuse  of  the  drug;  their  condemnation  has 
been  wholesale  thorouoh-fjoinG:  and  indiscriminate  itself: 
and  has  been  sometimes  the  blatant  utterance  of  iofnorance 
as  well  as,  at  times,  genuine  honest  criticism. 

Dr.  Murchison  has  put  the  position  of  mercury  very 
pointedly.  After  giving  the  results  of  numerous  experi- 
ments he  proceeds: — "Mercury  and  allied  purgatives  pro- 
duce bilious  stools  by  irritating  the  upper  part  of  the  bowel, 
and  sweeping  on  the  bile  before  there  is  time  for  its  reab- 
sorption.  The  fault  of  mercury  standing  at  the  bottom  of 
the  scale  of  cholagogues  in  ROhrig's  experiments  is  ac- 


262  LIVER  DISTURBANCE.  [chap.  xn. 

counted  for  by  its  surpassing  otlier  cholagogues  in  this 
property;  for  of  course  the  larger  the  quantity  of  bile  that 
is  swept  clown  the  bowel,  the  less  is  reabsorbed,  and  the 
less  escapes  from  a  biliary  fistula.  It  would  appear  that 
mercury  by  increasing  the  elimination  of  bile,  and  lessening 
the  amount  of  bile,  and  of  other  products  of  disintegrated 
albumen  circulating  with  it  in  the  portal  blood,  is  after  all 
a  true  cholagogue,  relieving  a  loaded  liver  far  more  effec- 
tually than  if  it  acted  by  merely  stimulating  the  liver  to 
increased  secretion  as  was  formally  believed,  and  as  some 
authorities  yet  maintain;  for  in  this  case  it  might  be 
expected  to  increase  instead  of  diminishing  hepatic  con- 
gestion." This  is  very  judicial.  But  Dr.  Murchison  pro- 
pounds another  view  essentially  his  own.  After  describing 
that  patients  of  undoubted  intelligence  are  certain  about 
the  benefit  they  derive  from  mercurials,  he  writes: — 
"It  is  not  impossible  that  the  good  effects  of  mercury 
on  the  liver,  and  in  some  forms  of  inflammation,  may  be 
due  to  its  property  of  promoting  disintegration.  It  seems 
not  improbable  that  mercury,  which  we  know  from  experi- 
ments to  reach  the  liver,  may  under  certain  circumstances 
act  beneficially  by  promoting,  or  in  some  way  influencing 
the  disintegration  of  albumen.  The  remarkable  effect  of 
mercury  on  constitutional  syphilis  perhaps  admits  of  a 
similar  explanation.  But  in  whatever  way  it  is  to  be  ex- 
plained, the  clinical  proofs  of  efficacy  of  mercury  in  certain 
derangements  of  the  liver  are  to  my  mind  overwhelming. 
I  say  so  the  more  advisedly,  because  I  was  taught  to  regard 
mercury  as  a  remedy  worse  than  useless,  not  only  in  he- 
patic diseases  but  in  syphilis:  it  cannot,  therefore,  be  said 


CHAP,  xn.]  LIVER  DISTURBANCE.  263 

that  the  convictions  forced  upon  mc  by  experience  are  the 
result  of  preconceived  opinion."  Dr.  Murchison  was  a 
pupii  of  the  hite  J.  Hughes  Bennett.  So  was  I;  and  T  can 
also  plead  that  my  belief  in  mercury  has  been  "  forced  upon 
me  by  experience,"  for  Bennett's  thundering  diatribes 
dominated  my  mind  for  a  long  time  ;  and  the  impression 
made  by  him  upon  my  youthful  mental  processes  was  only 
ground  out  by  the  resistless  action  of  au  accumulating 
experience. 

When  the  kidneys  are  extensively  diseased  a  marked  in- 
tolerance of  mercury  is  often  manifested;  and  like  opium 
i":  must  be  given  with  much  caution  then  ;  though  its 
utility  with  red  and  pink  lithates  is  incontestable.  In  the 
white  deposits  of  true  liver-indigestion  it  is  not  indicated. 
A  broad  rule  may  be  struck  to  this  effect — when  there  is 
atony  and  asthenia  mercury  is  contra-indicated;  but  when 
there  is  fair  power,  without  anjemia,  it  may  be  given. 
Always  bearing  in  mind  tliat  broad  rules  do  not  apply  to 
every  case;  and  where  individual  experience  has  demon- 
strated that  mercury  does  not  agree,  scrupulously  avoid  it. 
The  old  fashioned  plan  of  six  or  eight  grains  of  calomel 
for  acute  indigestion  may  suit  some  strong  persons;  but  it 
is  within  my  own  personal  experience,  not  of  my  own  pre- 
scribing it  is  almost  needless  'to  say,  that  such  reckless 
practice  has  done  immense  harm  to  a  delicate  patient. 
Mercury  is  one  of  those  "  edged  tools "  which  must  be 
handled  with  care  and  judgment.  When  the  patient  has 
found  opium  to  disagree,  whether  you  find  any  albumen' 
in  the  urine  or  not,  my  youthful  re^ders^  just  hold  your 
hand  about  merctiry  ;  it  is  not  necessary  tq   insist  upon 


264  LIVER  DISTURBANCE.  [chap.  xn. 

tliis  for  older  readers — they  have  found  it  out  for  them- 
selves. Another  broad  rule  may  be  put  thus  :  persons  of 
the  gouty,  sanguine,  or  arthritic  diathesis  bear  mercury 
much  better  than  do  those  of  the  strumous  diathesis. 
With  the  first,  the  action  of  mercury  in  disintegrating 
albuminoids  acts  beneficially  as  a  rule  ;  but  upon  the 
defective  constitutions  of  the  strumous  with  their  imper- 
fect tissue-building  (p.  72)  mercury  acts  too  energetically, 
and  in  a  very  undesirable  manner. 

When  to  give  a  dose  of  mercury  in  conditions  of  lithiasis 
and  albuminuria,  where  it  will  do  good  ;  and  when  to 
avoid  it  as  you  would  a  Cobra-di-Capello,  is  a  problem  in 
each  case  to  be  solved,  which  will  task  the  natural  powers 
and  the  acquired  skill  of  the  practitioner  to  the  utmost. 
Consequently  I  think  it  well  to  quote  a  passage  from  the 
second  edition  of  the  "Practitioner's  Handbook," — "Dr. 
Broadbent  informs  me  that  in  the  numerous  cases  of 
albuminuria  in  the  London  Fever  Hospital,  towards  the 
decline  of  the  affection,  when  only  small  quantities  of 
albumen  remain,  mercury  in  limited  doses  usually  leads 
to  the  entire  disappearance  of  the  albumen.  It  is  a 
remedy,  however,  which  should  be  resorted  to  cautiously; 
while  quite  a  safe  measure  in  the  hands  of  so  careful  a 
physician  as  Dr.  Broadbent,  it  may  be  a  very  dangerous 
agent  in  the  hands  of  some  practitioners."  So  in  certain 
cases  of  albuminuria,  not  consequent  upon  acute  fever, 
a  little  mercurial  may  be  very  beneficial;  but  in  every  in- 
stance it  should  not  be  given  until  the  case  has  been  made 
the  subject  of  patient  thought.  Given  careless!}'',  most  de- 
plorable results  may  follow.      A  tense  pulse  is  usually  a 


CHAP,  xn.]  LIVEE  DISTURBANCE.  265 


fair  iiidicalion  for  it.  The  wliole  subject  is  one  on  wlilcli 
we  all  desire  more  precise  in  formation. 

Aloes  is  an  agent  long  recognised  as  having  an  effect 
upon  the  liver.  So  is  rhubarb.  "  Many  persons  have 
succeeded  in  warding  off  bilious  attacks  to  which  they  are 
subject,  by  taking  habitually,  before  dinner,  a  few  grains 
of  rhubarb.  A  rhubarb  pill  will  often  relieve  a  slight 
bilious  disorder,  even  before  it  has  purged"  (Budd). 

Taraxacum  is  a  reputed  liver  stimulant,  much  in  vogue 
with  the  world  at  large,  and  with  herbalists;  but  little 
used  by  regular  medical  practitioners. 

Jalap,  colocynth,  and  senna,  are  also  cholagogues  of 
some  potency. 

Ipecacuan  is  an  hepatic  stimulant,  not  only  of  time- 
honoured  repute,  but  the  observations  of  clinical  medi- 
cine are  borne  out  by  the  physiological  experimentalist. 
Rutherford  found  it  to  be  one  of  the  most  potent  of  chola- 
gogues. Personally,  I  am  very  fond  of  giving  ipecacuan, 
especially  in  a  '*  dinner-pill;"  in  that,  following  a  practice 
which  has  been  all  but  obsolete  for  a  long  time,  but  which 
seems  likely  to  be  revived.  It  seems  to  obviate  the  action 
of  opium  upon  the  liver,  when  combined  with  that  drug, 
as  Dover's  powder. 

To  the  same  class  of  hepatic  stimulants  belong  "  Iridin," 

extracted  from  the  root  of  the  Iris  Versicolor,  now  much 

in    vogue.      Still    more    popular   is  "  Euonymin,"  derived 

from  the  bark  of  Euonymus  Atro-purpureus;  a  drug  now 

much   used    in    the    United    States    as    well    as  in  Great 

Britain.      "  Hydrastin,"  from    the   root  of  the  Hydrastis 

Canadenis,  possesses  allied  properties;  and  so  does  "  Jug- 
12 


266  LIVER  DISTURBANCE.  [chap.  xn. 

landin,"  a  resin  from  the  root  of  the  butter-nut  (Juglans 
Cinerea).  It  is  officinal  in  the  U.  S.  A.  "  Baptisin " 
from  the  root  of  the  Wild  Indigo  (Baptisa  Tincturia)  also 
possesses  a  moderate  stimulant  action  on  the  liver. 

Where  a  powerful  cathartic  is  required,  as  well  as  a  liver 
stimulant,  then  it  is  well  to  prescribe  podophyllin;  a  drug 
entitled  to  be  ranked  as  a  potent  cholagogue,  as  well  as  a 
purgative.  Of  allied  character  is  croton  oil,  popular  a 
generation  ago  for  the  treatment  of  lumbago  connected 
with  lithiasis. 

These  agents  are  all  useful  according  to  the  indications 
in  each  case  in  liver  trouble,  biliousness,  or  lithiasis;  and 
may  be  used  with  advantage,  as  cholagogues  and  hepatic 
stimulants. 

Of  a  totally  opposite  character  in  its  action  is  opium. 
We  cannot  separate  one  action  of  a  drug  from  its  otlier 
actions,  except  by  blocking  out  the  objectionable  action,  by 
combining  an  agent  of  antagonistic  properties.  Thus,  I 
systematically  use  belladonna  with  opium  in  the  severe 
cough  of  phthisis,  to  keep  off  the  night-sweats  induced  by 
it.  The  co-administration  of  ipecacuan  largely  prevents 
the  action  of  opium  upon  the  liver;  a  laxative  its  action 
upon  the  bowels.  But  this  action  of  opium  is  useful  when 
the  liver-ferment  converts  glycogen  too  freely  into  sugar; 
and  so  is  useful  in  the  treatment  of  diabetes.  In  azoturia, 
or  baruria,  where  there  is  a  neurosis  of  the  liver  splitting 
up  the  albuminoids  into  urea,  and  therewith  a  certain 
amount  of  bulima,  opium  also  is  useful.  It  puts  a  check 
upon  the  activity  of  the  liver;  and  this,  though  it  consti- 
tutes a  drawback  to  its  administration  ordinarily,  is  useful 
in  some  cases  of  excessive  action  of  the  liver-cells. 


CHAP,  xn.]  LIVER  DISTURBANCE.  267 

In  the  liver  disturbance  clue  to  j^yrexia,  quinine  lessens 
the  morbid  activity  of  the  viscera. 

Then  there  are  mineral  remedies  to  be  considered. 
Nitro-muriatic  acid  taken  by  the  mouth,  is  often  useful 
when  an  attack  of  jaundice  is  passing  away.  Some  like 
foot-baths  containing  it;  others,  a  lotion  of  it  upon  lint 
over  the  liver.  The  free  chlorine  in  this  acid  is  generally 
regarded  as  the  potent  factor.  Chloride  of  ammonium  is 
often  criven  therewith.  "  It  o^oes  with  either  acids  or  alka- 
lies"  (Murchison). 

Acids,  Murchison  thinks,  may  not  act  directly  upon  the 
liver,  but  may  do  good  indirectly  by  improving  gastric 
digestion.  In  some  cases,  he  holds,  both  acids  and  alka- 
lies may  be  given  advantageously — the  alkalies  before,  the 
acids  after  a  meal.  This  is  in  accordance  with  what 
Ringer  advocates;  tlie  alkalies  taken  when  the  gastric 
mucous  membrane  is  alkaline  excite  a  better  flow  of 
gastric  juice.  The  acids  given  during  the  period  of  gastric 
digestion  probably  aid -therein. 

Alkalies  are  more  in  favour  as  a  rule  than  acids,  in  the 
treatment  of  hepatic  affections.  Where  the  alkaline  bile 
is  insufficient  to  counteract  intestinal  acidity,  fixed  alkalies 
are  indicated  as  Prout  held  (p.  183). 

Soda  is  the  alkali  for  the  liver  ^:)ar  excellence.  Of  the 
common  condiment  of  our  food,  the  hydrochloric  acid  goes 
to  the  gastric  juice;  the  soda  to  the  bile. 

The  alkalies  are  good,  especially  potash,  in  rendering 
lithates  soluble.  According  to  Bence  Jones,  alkalies  are 
of  great  service  in  aiding  the  oxidising  processes  which 
go  on   in  the  body.      Some  persons,  however,  cannot  take 


268  LIVER  DISTURBANCE.  [chap.  xn. 

alkalies  without  extreme  depression.  I  know  a  stalwart 
Yorkshireman,  who  could  not  take  a  teaspoonful  of  effer- 
vescing citrate  of  potash  for  three  mornings  consecutively, 
without  experiencing  such  prostration,  produced  thereby, 
that  he  was  unfitted  for  business.  Others  aofain  can  take 
large  quantities,  not  only  with  impunity,  but  Avith  positive 
benefit.  Murchison  recommends  that  alkalies  should  be 
suspended  for  a  time,  as  they  may,  when  long-continued, 
hiterfere  with  gastric  digestion.  This  must  depend  upon 
the  evidences  of  each  case.  The  acid  bi-phosphate  of  soda 
is  an  excellent  solvent  of  lithic  acid,  according  to  Ritter 
von  Schroff,  and  might  be  substituted  for  the  ordinary 
alkali.  When  alkalies,  and  especially  potash,  depress,  it 
is  well  to  give  them  with  a  tonic.  Potash  is  a  muscle 
poison,  often  acting  powerfully  upon  the  heart.  It  is 
easy  to  counteract  this  action,  by  giving  with  it  an  agent 
which  increases  the  vigour  of  the  cardiac  contractions. 
When  alkalies  are  indicated,  they  should  not  be  taken 
with  meals,  or  during  the  time  of  the  gastric  digestion. 
This  is  too  obvious  to  require  much  insistance.  Even 
alkaline  waters,  as  Vichy,  Vals,  Seltzer,  or  Bath  water, 
should  not  be  drunk  at  meals;  neither  should  potass,  or 
lithia,  or  artificial  seltzer  water  be  taken  with  wine  or 
milk  then;  as  alkalies  neutralise  the  acidity  and  there- 
with the  activity  of  the  gastric  juice.  The  waters  of 
Carlsbad,  Marienbad,  Tarasp,  etc.,  may  be  drunk  early  in 
the  morning;  as  may  the  piore  potent  waters  of  Piillna, 
Frieclrichshall,  Hunyadi  Janos,  Estill  (Ky.),  or  Bedford 
(Pa.)  springs;  all  the  more  efficacious  with  a  little  warm 
water. 


CHAr.  xn.]  LIVER  DISTURBANCE.  2G9 

Sulphur  springs  are  useful  in  some  cases  of  biliousness, 
and  the  crowds  at  Harrogate,  drinking  the  waters,  and 
"  clearing  the  system,"  as  they  term  it,  of  the  vestigia  of 
persistent  over-eating  and  drinking,  tell  how  the  inhabi- 
tants of  the  manufacturing  towns  which  line  each  side  of 
the  slopes  of  the  backbone  of  England,  believe  in  periodi- 
cal purgation,  as  a  means  of  warding  off  the  evil  conse- 
quences of  over-indulgence  of  the  palate. 

Homburg  has  a  like  story  to  tell;  and  so  have  other 
watering  places.  As  the  subject  of  mineral  waters  will 
be  discussed  fully  in  the  succeeding  Part  II.,  when  gout  is 
being  specially  considered,  it  is  unnecessary  to  go  into  the 
subject  further  here. 

Chalybeates,  either  as  natural  waters  or  in  more  strictly 
medicinal  form,  are  contraindicated  in  all  cases  where  the 
action  of  the  liver  is  embarrassed;  and  never  should  be 
prescribed  until  the  tongue  is  perfectly  clean,  and  the 
digestion  and  assimilation  restored  by  appropriate  mea- 
sures. Iron  may  increase  the  activity  of  the  oxidizing 
processes  under  certain  circumstances;  but  when  there  are 
active  symptom.s  of  hepatic  disturbance  present,  it  does 
harm  and  not  good.  About  that  I  have  long  been  certain. 
If  the  reader  wish  to  know  more  about  this  matter,  he  can 
consult  the  article  "  When  not  to  give  Iron,"  The  Practi- 
tioner, Sept.,  1877,  or  the  second  edition  of  xnj  Practitioner'^ s 
Ha^alhook.  Murchison  says: — "  In  simple  lithaemia  I  have 
constantly  known  iron  to  increase  the  tendency  to  deposits 
of  lithates  in  the  urine,  constipate  the  bowels,  and  aggra- 
vate any  symptoms  from  which  the  patient  may  have  pre- 
viously suffered."     Dr.  Garrod  writes: — "It  is  important 


270  LIVER  DISTURBANCE.  [chap.  xn. 

that  great  attention  should  be  paid  to  the  condition  of  the 
bowels  and  liver  during  the  exhibition  of  iron  preparations; 
which  he  thinks  "  are  for  the  most  part  contraindicated  " 
in  conditions  of  lithiasis.  The  wish  to  hasten  the  patient's 
convalescence  is  a  laudable  one;  but  to  give  iron  prema- 
turely is  often  to  illustrate  the  adage  "  the  more  haste  the 
less  speed." 

Tonics  generally  are  of  questionable  value  until  their 
appropriate  time  has  arrived,  viz.,  after  a  certain  progress 
has  been  made.  The  lighter  bitters,  as  quassia,  gentian, 
chiretta,  or  cascarilla,  suit  better  than  cinchona  or  quinine, 
as  a  rule,  at  first.  Strychnia  or  nux  vomica  is  a  capital 
tonic,  stimulating  the  liver  as  well  as  the  peristaltic  move- 
ments of  the  bowels,  especially  indicated  where  there  is 
flatulence.  Phosphorus  was  often  of  service  in  lithoemia 
according  to  Murchison.  .Arsenic  he  thinks  often  useful 
where  chalybeates  disagree;  a  statement  corroborated  by 
my  own  experience. 

Now  the  junior  section  of  my  readers  may  feel  as  if  they 
would  like  some  more  precise  indications  about  the  use  of 
the  agents  just  mentioned.  Under  what  circumstances  to 
prefer  one' agent;  and  why  at  other  times  another  should 
be  selected.  This  is  very  natural,  and  as  far  as  the  sub- 
ject permits  of  such  handling,  I  will  try  to  tell  them.  But 
unfortunately,  only  very  broad  rules  can  be  laid  down,  and 
each  case  requires  its  own  individual  treatment:  just  as 
each  man  requires  his  clothes  to  fit  him,  as  differentiated 
from  some  one  else.  It  may  then  be  said  that  hepatic 
stimulants  are  indicated  for  permanent  use,  to  "give  a 
fillip"  to  the  liver,  as  the  common  phrase  runs.      These 


CHAP,  xn.]  LIVER  BISTURBANCE.  'Ill 

are,  ipecacuan,  hydrastin,  euonymin,  iridin,  and  baptisin, 
and  their  congeners,  with  aloes,  rhubarb,  colocyntli,  jalajD, 
or  senna,  as  laxatives,  with  carminatives  in  pill,  combined 
as  required;  or  the  more  potent  podophyllin,  croton  oil, 
or  gamboge,  wliere  there  is  stubborn  constipation.  To 
these  may  be  added  arsenic  or  strychnia,  according  to  the 
phenomena  exhibited  by  certain  cases.  Such  may  be 
termed  the  permanent  treatment  of  the  disorder;  to  be 
continued  for  some  time. 

Then  for  conditions  of  aggravation,  or  acute  disturbance, 
it  is  well  to  give  a  pill  containing  some  mercurial  at  bed- 
time; and  next  morning  some  sulphate  of  soda  with  an 
alkali.  Twice  or  thrice  a  week  this  may  be  done  with  de- 
cided advantao^e  to  the  case:  the  dietarv  at  the  same  time 
being  carefully  regulated  and  adapted  to  the  patient. 

In  some  cases  warm  baths  seem  to  have  an  excellent 
effect  both  upon  the  liver  and  the  skin;  while  at  othe^ 
times  a  large  hot  poultice  over  the  liver  stimulates  it  most 
satisfactorily.  A  poultice  is  clearly  indicated  with  those 
persons  who  either  cannot  take  much  medicine  by  the 
mouth,  or  who  are  disinclined  to  try.  In  cases  of  "  bilious 
chill,"  such  a  measure,  in  addition  to  the  medicine  appro- 
priate thereto,  is  often  of  service.  But  "the  acquired  ex- 
perience of  the  individual,"  won  by  the  sweat  of  his  brow, 
can  no  more  be  transferred  bodily  to  another,  than  can 
how  to  wield  a  stethoscope,  or  see  correctly  through  a 
microscope;  or  the  apparently  simpler  matter,  alluded  to 
before,  of  keeping  six  balls  in  tlie  air  at  once,  a  common 
juggler's  feat,  or  Mr.  Maskelyne's  skill  in  keeping  his  nu- 
merous plates  spinning.     The  aspirant  may  be  told  "  how 


272  LIVER  DISTURBANCE.  [chap.  xii. 

to  do  "  each  of  these;  but  to  ^'  do  "  them  he  must  learn  for 
himself:  there  is  no  ^' royal  road"  to  it,  nor  can  a  "cram- 
mer "  do  it  for  him. 

Beyond  the  medicinal  treatment  lies  the  dietary,  on  which 
it  is  not  now  necessary  to  be  diffuse  after  what  has  been 
said  in  the  two  preceding  chapters.  The  great  fact  there 
insisted  upon,  and  reiterated,  is  that  it  is  not  the  hydro- 
carbons of  our  food,  but  the  albuminoids  which  are  tlie 
source  of  trouble;  alike  in  "biliousness"  and  in  "liver- 
indigestion."  The  readily  oxidisable  hydrocarbons,  when 
an  excess  of  food  is  taken,  are  burnt  up  first;  or  in  other 
words,  upon  the  hydrocarbons  the  respired  oxygen  is  ex- 
pended, leaving  the  less  readily  oxidisable  albuminoids 
iiaperfectly  acted  upon.  In  such  manner  is  a  certain  por- 
tion of  disturbance  in  the  metabolism  of  albuminoids 
brought  about.  This,  indeed,  is  the  explanation  of  the  de- 
rangement set  up  by  a  "  surfeit  "  by  over-indulgence  in 
food.  This  must  be  clearly  differentiated  from  the  perver- 
sion of  metabolism  which  is  a  vicious  habit,  the  albumin- 
oids being  split  up  into  uric  acid  rather  than  urea.  The 
reader  must  distinguish  betwixt  these  two  forms  of  liepatic 
derangement,  else  his  2:)ractice  and  treatment  will  be  un- 
satisfactory. For  the  first,  more  discretion  is  indicated  in 
the  future,  especially  with  those  who  possess  a  congenitally 
incompetent  liver.  Nevertheless,  with  all  children  it  is 
w^ell  to  avoid  excess  in  eating.  Probably  the  children  of 
the  present  are  no»t  any  more  addicted  to  over-eating  than 
their  predecessors;  but  it  is  probable  they  cannot  do  it  with 
the  same  impunity.  The  digestive  organs  are  not  in  "  these 
degenerate  days "  equal  to  those  tremendous  disjDlays  of 


CHAP,  xn.]  LIVER   DISTURBANCE.  273 

capacity  with  which  our  ancestors,  in  their  juvenile  years, 
have  been  credited;  on  the  other  hand  juvenile  parties,  the 
increasing  use  of  sugar — due  to  its  comparatively  low  price 
— and  the  prevalence  of  rich  cakes  at  tlie  present  time,  con- 
stitute a  species  of  temptation  to  the  present  generation 
which  they  cannot  always  successfully  resist.  That  a  bil- 
ious attack  is  a  corrective  as  well  as  a  curative  agent  must 
be  admitted;  and  the  memory  of  the  suffering  helps  the 
future  resistance  to  temptation.  Still,  children  are  but 
children,  and  a  superintendence  by  their  seniors  is  re- 
quisite and  necessary.  Most  children  can  be  controlled  ; 
but  there  are  some  unwholesome  children  who  will,  fully 
conscious  of  the  consequences,  gorge  themselves  when  a 
supply  of  "good  things"  is  available,  and  will  not  practice 
moderation.  Such  children  are  usually  the  offspring  of 
foolish  parents,  who  will  not  look  ahead  in  the  matter  of 
consequences;  and  upon  whom  all  warnings  fail  unheeded. 
Maudsley  says  that  the  difficulty  of  dealing  with  the  in- 
sane lies  chiefly  in  their  half-cracked  relatives.  So  with 
these  foolish  children  the  difficulty  lies  in  their  silly  parents; 
who  do  not  see,  or  will  not  be  made  to  see,  what  the  future 
consequences  w^ll  be,  that  the  child  wull  grow  up  the  sub- 
ject of  biliary  disorder  which  will  cripple  its  working  power 
and  embitter  its  existence.  For  such  children,  some  one 
interested  in  them,  who  has  their  welfare  at  heart,  must 
exercise  for  them,  and  in  their  behalf,  the  control  in  w^hich 
they  themselves  are  deficient.  With  adults  the  case  is 
different;  and  they  individually  know  better,  if  they  only 
will  try  to  exercise  self-restraint.  Yet  often  such  persons 
are  wilful,  arguing  that  they  **  may  as  well  have  a  good 
.     13* 


274  LIVER  DISTURBANCE.  [chap.  xn. 

rue  (regret)  as  a  bad  one,"  i.e.,  if  they  are  going  to  make 
themselves  ill  they  might  as  well  do  it  thoroughly;  balan- 
cing the  enjoyment  of  the  eating  against  the  pains  of  the 
"bilious  attack."  In  such  cases  little  can  be  done;  for 
there  are  some  persons  whom  even  experience  cannot  teach. 
Still,  counsel  and  warning  may  do  some  good  if  persisted 
in.  These  are  the  persons  who,  instead  of  practising 
moderation  when  their  Nemesis  overtakes  them,  or  even 
when  they  apprehend  that  punishment  is  in  pursuit  of 
indulgence,  fly  to  the  antibilious  pill  and  the  morning 
draught,  either  black-draught,  Hunyadi  Janos,  or  efferves- 
cent citrate  of  magnesia.  By  so  doing  they  educate,  or 
cultivate  a  vicious  habit,  and  like  other  foolish  people 
''reap  as  they  have  sown,"  and  become,  in  time,  the^ub- 
jects  of  well-established  hepatic  derangement.  Such  "  bil- 
ious "  individuals,  lacking  in  discretion,  are  usually  to  be 
found  amongst  the  female  sex,  but  not  exclusively  so;  and 
are  usually  comparatively  young. 

This  brings  up  the  matter  of  clinical  observation  that 
such  "bilious"  individuals  become,  in  middle-age,  dyspep- 
tic or  gouty.  This  is  a  very  interesting  matter  for  con- 
sideration; the  explanation,  however,  not  3^et  being  cleared 
up.  The  liver  seems  to  become  further  disordered,  and 
instead  of  an  excess  of  bile-acids,  produces  an  excess  of 
lithates.  It  would  aj^pear,  for  it  would  not  be  judicious  to 
put  the  matter  more  strongly,  that  in  the  system,  while 
young,  any  excess  takes  the  direction  of  biliary  disturb- 
ance, the  bowels  being  chiefly  implicated,  and  the  urine 
being  high-coloured,  and  of  high  specific  gravity,  but  not 
otherwise  altered  in  character;  while  in  more  advanced 


CHAP,  xn.]  LIVER  DISTURBANCE.  275 

life  there  is  indigestion  with  the  production  of  quantities 
of  lithates,  usually  of  pale  color,  when  any  indiscretion  in 
diet  has  been  committed.  While  the  explanation  is  not 
vet  forthcominof,  still  it  is  well  to  bear  the  association  in 
mind  as  throwing  a  strong  light  upon  the  function  of  the 
liver,  and  the  relations,  clinical  as  well  as  chemical,  be- 
twixt the  bile-acids  and  the  urine  solids.* 

This  matter  tells  very  articulately  that  the  dietary 
adapted  to  lithiasis  is  also  that  suited  to  biliousness, 
viz.,  a  non-nitroo;enised  dietarv.  If  I  seem  to  insist  on 
til  is  matter,  usque  ad  nauseam,  my  apology  must  be  that 
the  impression  that  it  is  the  hydrocarbons  of  our  food 
which  are  at  fault,  is  so  universal,  so  deep-rooted,  that  it  is 
necessarv  to  be  explicit.  It  is  not  *'  flooforino^  a  dead  horse  " 
to  speak  dogmatically  on  this  matter,  for  multitudes  of 
persons  are  making  themselves  ill-,  destroying  their  pros- 
pect of  future  comfort  and  physical  well-being,  by  errone- 
ous imj^ressions  leading  to  injurious  practices.  They  live 
upon  the  lean  of  a  chojD,  some  dry  bread,  and  tea  or  coffee 
without  sugar  or  cream,  with  much  self-denial  in  the  vain 
and  delusive  search  after  health,  or  an  approach  thereto: 
instead  of  a  farinaceous  dietary  with  stewed  fruit.  This 
is  open  heresy  flaunting  itself,  I  am  quite  aware,  in  their 
eyes.  Further,  I  am  also  quite  aware,  that  such  a  meal 
as  has  just  been  described,  is  more  digestible  at  the  time 

*  It  may  be  -well  to  contrast  the  chemical  formulas : 
Taurin  CoH.XO^S  .  Urea  C0H4X2O2 

Glycogin  CQH5NO2  Uric  Acid  CioHiNiOc-MHO 

Bilirubin  C6Hig;!Sr203  Biliverdin  CisHooNsOi 

There  is  a  generic  resemblance,  if  nothing  more  or  closer. 


276  LIVER  DISTURBANCE.  [chap.  xn. 

it  is  taken;  will  admit  it  is  perhaps  the  only  sort  or  kind 
of  meal  which  can  be  taken  without  discomfort.  Neverthe- 
less, it  distinctly  tends  to  perpetuate  the  trouble;  while 
the  other  dietary,  less  attractive  at  first,  perhaps  even  re- 
pulsive, and  provocative  of  repugnance,  is  the  one  cal- 
culated to  produce  an  improvement  ultimately.  It  is  the 
question  of  the  future  versus  the  present.  Present  comfort 
and  future  discomfort;  or  present  self-denial  with  future 
improvement.  It  is  the  old,  old  story  of  resisting  tempta- 
tion, or  giving  way  to  it,  with  future  rewards  and  punish- 
ments meted  out  accordingly. 

In  great  matters  so  in  small;  to  resist  present  tempta- 
tion is  to  secure  future  happiness — to  merit  a  future 
reward;  and  in  this  case  the  certainty  of  the  reward  is 
such,  while  not  too  far  distant,  as  to  make  it  blind  folly 
not  to  practice  the  present  self-denial  which  is  requisite 
for  its  ultimate  attainment.  As  in  theology,  so  in  hygiene, 
the  w^hole  question  is  w^hether  the  faith  is  a  living  faith — 
vital,  and  capable  of  inspiring  conduct — or  not.  A  faith 
that  is  not  equal  to  inspiring  conduct  is  a  hollow  gourd, 
a  delusion  and  a  snare;  if  not,  indeed,  a  sham. 

Another  matter  there  is  about  which  something  may  be 
appropriately  said  at  this  point,  just  as  well  as  anywhere 
else,  which  is  connected  with  the  liver,  on  which  an 
erroneous  opinion  is  prevalent.  We  have  seen  that  urea 
is  a  product  of  the  liver.  We  know  that  the  liver  is  the 
furnace  in  which  effete  blood-corpuscles  and  tissue-debris 
are  burnt;  there  is  no  question  about  that.  But  while 
admitting  and  acknowledging  all  this,  it  does  not  follow 
that  all  the  urea  has  once  been  tissue.      That  is  an  as- 


CHAP,  xn.]  LIVER  DISTURBANCE.  'Til 

sumption  not  warranted  by  the  facts.  ^Ye  know  that  the 
liver  also  disposes  of  the  luxiis  consumption  of  the  albu- 
minoid materials  of  our  food.  Let  us  see  what  Prof.  M. 
Foster  says: — "In  dealing  with  the  statistics  of  nutrition, 
our  attention  will  be  drawn  to  the  fact  that  the  introduc- 
tion of  proteid  matter  into  the  alimentary  canal  is  foUoAved 
by  a  large  and  rapid  excretion  of  urea,  suggesting  the  idea 
that  a  certain  part  of  the  total  quantity  of  urea  normally 
secreted  comes  from  a  direct  metabolism  of  the  proteids  of 
our  food,  without  these  really  forming  a  part  of  the  tissues 
of  the  body"  (3rd  edit.,  p.  404).  Yet  for  some  years  back 
we  have  been  told  of  the  amount  of  urea  passed  by  fever- 
patients,  as  representing  so  much  tissue-waste.  It  was 
assumed,  quite  gratuitously^  it  would  appear,  that  urea  was 
the  final  stage  of  what  was  once  tissue,  whether  ordinary 
muscular  fibre  or  blood-corpuscle;  and  on  this  hypothesis 
rested  one  side  of  the  arch.  The  fact  that  in  fever  the 
muscles  waste,  and  that  at  a  high  temperature  the  albu- 
minoid tissues  melt  down,  constituted  the  base  of  the  other 
half  of  the  arch.  The  complete  arch  was  this — the  amount 
of  urea  found  in  the  urine  is  the  measure  of  the  tissue- 
waste  !  It  is  not  necessary  to  refute  this  at  length.  If 
not  a  "dead  horse,"  it  certainlv  ous^ht  to  be.  Such  an 
idea  should  be  as  extinct  as  the  dodo. 

This  is  a  digression,  but  not  a  waste  of  time,  I  venture 
to  think.  It  helps  to  introduce  what  I  am  about  to  say 
as  to  the  dietary  in  conditions  of  "  biliousness "  and  of 
*' liver  indio-estion." 

A  certain  portion  of  the  albuminoid  elements  of  our  food 
passes  into  the  albumen  of  the  liquor  sanguinis;  another 


278  LIVER  DISTURBANCE.  [chap.  xii. 

portion  passes  into  the  bile-acids;  while  a  third  passes 
into  urea.  This  is  solid  ground.  The  liver  performs  the 
work  of  elaboration  in  the  first  case;  of  destructive  meta- 
morphosis in  the  second  and  third.  Plas  the  liver  a  selec- 
tive function  ?  Does  anything  go  on  in  the  liver  such  as  goes 
on  in  human  manufactories,  namely,  a  selection  of  the  fit, 
with  a  rejection  of  the  unfit  ?  In  Messrs.  Rodgers'  Cutlery 
Establishment  at  Sheffield,  bones  and  ivory  are  cut  up  for 
knife-handles:  of  these  only  some  pieces  are  fit  to  be  used. 
The  fit  pieces  are  passed  on  to  the  knife-handle  maker,  to 
be  made  into  the  hafts  of  knives:  the  rejected  pieces  are 
passed  on  to  the  refuse  heap,  to  be  ground  up  into  bone- 
dust  used  to  clean  plate.  Is  there  any  analogous  action 
in  the  liver;  any  selective  choice  by  which  certain  proteid 
matter  is  selected  for  further  elaboration;  while  other  pro- 
teid matter  is  rejected,  and  either  burned  up  into  urea, 
or  utilised  in  a  lowlier  form  as  the  bile-acids  ?  We  do  not 
know;  we  may  never  know.  It  is  not  likely  anyhow  that 
this  can  be  ascertained  in  the  life-time  of  the  present 
generation.  We  can  only  see  through  a  glass  darkly. 
Our  successors  may  be  able  to  see  all  in  the  bright  light 
of  noonday.  Some  such  selective  action  seems  probable. 
Is  this  the  smoke  which  precedes  the  fiash;  as  is  said  on 
the  Russian  steppes  ?  Is  this  the  shadow  projected  forward 
of  a  future  solid  something;  of  what  physiology  may  some 
day  in  the  far  distance  make  solid  ground  for  us?  We 
cannot  say.  This  much  may  be  averred,  that  some  such 
"notion"  would  make  "a  good  working  hypothesis," 
which  would  be  a  useful  guide  to  us  in  our  daily  practice. 
It  would  help  to  clear  our  views,  that  of  the  proteid  ele- 


CHAP,  xn.]  LIVER  DISTURBANCE.  279 

mcnts  of  our  food,  a  portion  only  passes  on  into  tissue. 
Tliat  much  of  the  remainder  is  either  burnt  as  so  much 
fuel,  a  fuel  leaving  a  tremendous  residuum  of  ash;  or  is 
utilised  in  a  lowlier  form.  The  ash  is  the  urea.  The  low- 
lier form  is  the  bile-acid,  which  emulsionises  fats  in  the 
duodenum.  The  matter  must  be  left  here;  and  our  curi- 
osity must  pause  unsatisfied,  nay  dissatisfied,  led  up  to 
the  gates  of  the  promised  land — and  left  there. 

From  this  vision,  mirage,  or  reality,  who  can  tell,  w^e 
may  now  turn,  and  scrutinise  the  reality  of  clinical  facts. 
These  facts  we  know,  recognise,  and  are  familiar  with  in 
practice;  albeit  a  bit  muddled  from  erroneous  explanation. 
The  theory  that  bile  comes  from  the  hydrocarbons  of  our 
food,  is  an  ignis  fatuus,  which  led  our  predecessors  into  a 
morass.  It  underlay  the  dietary  spoken  of  recently  (p. 
172),  which  though  acceptable  to  the  palate  and  perhaps  to 
the  alimentary  canal, — the  solvent  portion  of  the  digestive 
act,  is  nevertheless  the  perpetuating  factor  of  the  hepatic 
derangements.  Such  at  least  I  hold  it  to  be.  Too  exclu- 
sively albuminoid,  it  maintains  and  keej^s  up  the  morbid 
condition.  It  throws  too  much  work  upon  the  liver,  if 
easy  of  digestion  in  the  alimentary  canal.  Starch  may  be 
hard  of  digestion  as  regards  its  solution  and  progress  to 
grape-sugar  in  the  portal  vein;  but  then  it  gives  no  further 
trouble  in  its  future  history.  The  lean  of  a  chop  may 
neither  cause  pain  nor  flatulence,  on  its  way  to  being  con- 
verted into  peptones;  but  its  after  history  is  less  satis- 
factory. The  advocates  of  raw  meat  for  the  treatment  of 
indigestion  may  claim  that  it  is  acceptable  to  the  stomach: 
but  the  liver  may  not  be  pleased  therewith.     Ayoungman 


280  LIVER  DISTURBANCE.  [cilvp.  xn. 

may  find  favour  in  a  girl's  eyes,  but  her  parents  may  not 
be  satisfied  with  him.    Acceptable  enough  to  her;  the  very 
qualities  which  weigh  favourably  with  her,  may  be  those 
on  which  her  father  especially  founds  his  objections.  That 
food  which  is  acceptable  to  the  stomach  may  be  the  very 
matter  which  disturbs  the  liver.     Indeed  it  is  these  very 
alouminoids  which  are  the  subjects  of  gastric  peptic  diges- 
tion, and  which  sit  easily  upon  the  stomach,  that  we  sus- 
pect as  most  readily  "  taking  to  evil   ways  "  in  the  liver; 
and  instead  of  proper  metabolism  or  elaboration,  proceed- 
ing downwards  to  bile-acids  or  urine  solids.      They  are 
the    suspected   anyhow  !     In  practice    it  is  necessary  to 
discriminate  betwixt  the  immediate  present  and  that  which 
lies  outside  and  beyond   it.     A   patient  may  truthfully 
affirm  that  the  lean  of   a  chop,  a  little  dry  bread,  with  a 
cup  of  tea  without  milk  or  sugar,  is  the  meal  which  causes 
the  least  suffering,  and  agrees  the  best.     But  it  does  not 
follow,  I  assert,  that  this  is  the  food  therefore  indicated  for 
the  patient,  or  really  best  suited  to  the  requirements  of  the 
case.    Physiology  must  be  our  guide  and  interpreter;  and 
not   the  subjective   sensations   of  the  patient  during  the 
digestive  act.     Not  that  these  latter  are  to  be  utterly  dis- 
regarded: but  they  must  not  dominate  us,  or  be  allowed 
to  silence  all  other  voices  in  their  own  assertive  tones. 
They  must  be  listened  to,  but  only  so  far;  no  further. 

Having  thus  differentiated  clearly  betwixt  what  is  agree- 
able and  what  is  good;  what  is  acceptable  at  the  time, 
and  what  is  clearly  desirable  in  the  future  interests  of  the 
patient:  it  may  be  well  to  lay  down  rules  for  the  dietary 
in  conformity  with  what  physiology  teaches.     When  the 


CHAP,  xn.]  LIVER  DISTURBANCE.  281 

patient  is  »idvised  to  make  stewed  fruit  and  cream,  or  a 
milk-pudding,  a  staple  article  of  diet;  to  have  it  prepared 
always  for  dinner,  and  to  have  what  is  left  over  at  dinner 
for  breakfast  next  morning;  dismay  spreads  over  the  fea- 
tures. There  is  something  so  utterly  un-English  in  such 
a  breakfast,  that  the  patient  looks  horrified.  Yet  a  great 
variety  of  fruit,  and  of  dishes  of  milk  and  farinaceous  mat- 
ters are  available  for  the  purpose;  and  this  does  not 
involve  monotony,  a  thing  most  carefully  to  be  avoided 
in  all  dietaries.  Nothing  prejudices  a  patient  against  a 
dietary  more  powerfully  than  poverty  in  the  number  of 
dishes  available.  A  short  list  is  distinctly  deterrent.  So  it 
is  well  to  point  out  that  in  addition  to  the  fruits  which  are 
indiofenous,  and  which  are  readilv  available  each  according 
to  their  season,  there  are  a  large  variety  now  to  be  pro- 
cured at  any  time,  put  up  in  tins.  For  instance  there 
are  grapes,  cherries,  strawberries,  raspberries,  figs,  peaches, 
apricots,  pineapples,  apples,  pears,  plums,  pumpkins,  mel- 
ons, cranberries,  guavas,  and  others.  Or  the  dried  fruits, 
Normandy  pippins,  apple-rings,  dried  peaches,  pruneilos, 
French  plums,  figs  ;  all  of  which  are  excellent  stewed. 
Then  the  milk-pudding  can  be  made  with  corn-flour, 
hominy,  rice,  tapioca,  sago,  crushed  cereals,  and  other  fari- 
naceous matter,  so  as  to  furnish  variety.  With  a  little 
exercise  of  her  ingenuity,  the  housewife  can  make  a  num- 
ber of  combinations  rendering  anything  like  monotony  out 
of  the  question.  That  is  if  she  will  try  I  One  thing  it  is 
well  to  bear  in  mind,  that  in  these  cases  where  it  is  desir- 
able to  avoid  albuminoids,  it  is  well  to  make  these  milk- 
puddinsrs  without  e2-o:s.     Thev  -are  almost  as  toothsome 


282  LIVEE  DISTURBANCE.  [chap.  xn. 

without,  and  suit  much  better.  Then  there  are  blanc- 
manges, made  without  isinglass,  which  may  be  utilised. 
Or  there  are  various  fruit  creams,  which  can  be  had  ac- 
cording to  the  season.  Strawberries,  gooseberries  (goose- 
berry-fool is  also  good),  black-currants,  wine-currants, 
red  and  white,  which  may  be  made  with  creams,  or  eaten 
as  they  are.  The  dread  of  sweets  which  has  obtained  will- 
interfere  to  prevent  the  adoption  of  such  a  dietary;  but  I 
ask  the  patient  to  give  it  a  fair  trial.  When  tliis  is  done  I 
venture  to  think  the  results  will  please  them;  as  they  have 
proved  satisfactory  to  me.  The  salts  in  fruits  may  not  be 
great  in  quantity  but  they  are  certainly  operative,  as  we  see 
in  the  prevention  of  scurvy.  A  recent  expedition  in  the 
Arctic  regions  found  under  the  snow  a  little  sour  red  berry 
which  they  gathered  and  preserved  in  barrels  for  use  in 
their  sledge-expeditions,  and  so  prevented  scurvy;  their 
conduct  in  this  respect  contrasting  favorably  with  the 
contemptuous  disregard  of  such  well  known  facts  as  the 
efficacy  of  the  sub-acid  fruits,  especially  of  all  vegetables, 
in  staving  off  scurvy,  exhibited  by  the  English  under 
Captain  Clements  Markham.  These  salts  are  good:  while 
the  use  of  fruit  regulates  the  bowels,  a  matter  of  impor- 
tance in  all  derangement  of  the  liver;  whether  bile-acids  or 
lithates  are  involved.  In  consequence  of  the  amount  of 
egg  in  it,  custard  is  objectionable.  The  yolk  of  an  egg 
added  to  the  milk  however  is  permissible.  This  combina- 
tion of  fruit  with  milk  and  farinaceous  matters,  should  be 
made  one  of  the  cardinal  points  of  the  dietary.  If  the 
patient  feel  "  bilious  "  under  this  regimen,  a  morning  laxa- 
tive once  or  twice  a  week  will  be  found  to  carry  off  any 
superfluity  which  is  disagreeing  in  the  dietary. 


CHAP,  xn.]  LIVER  DISTURBANCE.  283 

Then  there  arc  vegetables  to  be  considered.  Potatoes 
boiled,  steamed,  masiied,  or  passed  through  a  sieve,  eaten 
with  milk  and  butter,  are  good  for  lunch  or  dinner:  pro- 
vided always  that  they  be  thoroughly  disintegrated.  Few 
things  offend  a  stomach  more  than  a  piece  of  hard  un- 
chewed  potato,  upon  which  the  stomach  can  exercise  no 
influence  whatever.  The  same  applies  to  greens  generally, 
brocoli,  Brussels  sprouts,  cabbages,  and  cauliflowers;  and 
holds  good  of  vegetable  marrow.  This  last,  like  cauliflower, 
may  be  cooked  au  gratin,  but  should  be  eaten  with  care  and 
sparingly.  Peas  and  beans,  French  beans,  and  scarlet-run- 
ners, all  are  admissible  in  limited  quantities  only;  as  con- 
taining a  large  proportion  of  albuminoid  matter,  caseine. 
Then  there  are,  carrots,  turnips,  parsnips,  beet,  asparagus, 
sea-kale,  boiled  celery,  onions,  and  leeks.  All  these  are 
permissible  as  regards  their  chemical  composition,  and  do 
not  tax  the  liver;  but  there  is  the  stomach  to  be  consulted, 
and  that  is  a  matter  not  to  be  forgotten.  In  each  case, 
therefore,  it  must  be  made  a  matter  of  experience,  what 
agrees,  and  what  does  not;  and  this,  and  not  any  rule  of 
thumb,  must  be  made  the  guide  for  the  future  in  the  diet- 
ary. The  same  must  be  said  of  salads  in  their  various 
forms.  They  are  not  to  be  prohibited  provided  they  do 
not  disaoree. 

Now  of  fishes,  salmon  certainly  is  objectionable,  least  so 
plain  boiled,  hot  or  cold,  and  it  is  well  to  avoid  cucumber 
with  it.  Then  fried  sole  is  verv  indi2:estible.  Plain  boiled, 
it  is  permissible.  Mackerel  and  herring  are  undesirable, 
unless  plain  boiled.  The  flesh  of  the  turbot,  brill,  halibut, 
skate,  or  plaice,  is  admissible,  and  so  is   that  of  the  gur- 


284  LIVER  DISTURBANCE.  [chap.  xit. 

net,  and  John  Dory,  what  there  is  of  it.  Cod-fish  is  very 
well  suited,  whether  fried,  boiled,  or  augratin,  or  as  a  fish- 
pudding  with  mashed  potatoes.  Ling  is  unobjectionable, 
so  is  the  haddock.  Whiting,  "the  chicken  of  the  sea," 
is  excellent.  So  is  red  mullet;  less  so  gra^^  mullet.  Trout 
are  good  in  limited  quantities.  Eels  are  apt  to  disagree 
with  the  stomach.  Shrimps  and  prawns  and  good;  so  are 
crayfish.  The  lobster  and  crab  are  apt  to  upset  the  stom- 
ach, otherwise  they  may  be  eaten  in  moderation.  Oysters 
are  good,  and  so  are  mussels,  for  those  who  like  them. 

Of  fowls,  fair  quantities  may  be  taken;  but  their  flesh  is 
rich  in  albuminoids,  be  it  remembered.  First  cgmes  the 
chicken,  boiled;  cold,  with  or  without  salad,  if  the  stomach 
approves.  Then  the  pigeon,  the  pheasant,  and  the  par- 
tridge, grouse,  black-game,  capercailzie,  prairie-fowls, 
quails,  snipe;  all  in  limited  quantities  are  permissible.  The 
duck  and  the  goose,  and  the  turkey,  unless  it  be  a  little  of 
the  breast,  are  to  be  avoided. 

Of  "  flesh-meat,"  pork  is  poison.  Beef  is  less  objection- 
able; and  so  is  mutton.  A  little  of  either,  cold,  may  be 
taken  at  lunch.  Yeal  is  to  be  avoided;  unless  it  be  in  the 
form  of  sweet-bread.  Lamb's  fry  is  permissible;  or  lamb's 
head  boiled  is  often  nice  for  a  weak  stomach. 

Of  potted  meats  they  offer  no  difficulties  in  the  way  of 
disintegration;  any  may  be  taken  sparingly  as  sandwiches, 
made  with  thin  slices  of  stale  bread,  with  the  butter  rubbed 
well  into  the  bread,  and  spread  not  too  thick. 

Bread  may  be  eaten,  best  stale,  or  as  whole-meal  bread; 
then  biscuits  are  digestible.  Toast  tempts  some.  Farina- 
ceous   matter   may    be    cooked    with   milk,    as    oatmeal- 


CHAP,  xn.]  LIVER  DISTURBANCE.  285 

porridge,  hominy,  steam-crushed  cereals,  "  Cerealine,"  a 
delightful  combination,  good  in  many  ways.  Boiled  with 
milk  and  poured  into  a  pie-dish  to  stand  over-night;  and, 
next  morning,  cut  in  slices  and  fried,  it  looks  like  the  most 
tempting  white  fish,  and  is  delicious.  Hominy,  so  treated 
also,  is  good.  Indeed,  if  farinaceous  foods  agree  with  the 
patient,  a  large  variety  of  simple  dishes  can  be  prepared, 
especially  with  milk. 

Soups  are  contraindicated,  unless  it  be  a  little  gravy 
soup,  the  poorer  the  better. 

Pastry  is  objectionable  on  account  of  its  indlgestibility 
in  the  stomach.  But  with  those  with  whom  it  does  not 
disagree,  there  is  no  objection  to  its  use. 

For  further  information  as  to  dishes  and  their  prepara- 
tion, the  reader  is  referred  to  Food  for  the  Invalid,  the 
Convalescent,  the  Dysjyejytic,  and  the  Gouty,  by  the  writer, 
published  by  Messrs.  Macmillan  &  Co. 

(Each  dish  requiring  such  indication  is  marked  with 
certain  initials;  the  interpretation  of  which  is  given 
therein  at  pp.  26-27.  It  is  well  to  follow  what  is  written 
there,  and  all  dishes  containins:  meat  should  be  taken  in 
moderation.) 

The  sort  of  daily  dietary  to  be  arrived  at  has  been 
sketched  out  in  Chap.  viii.  p.  139,  as  suited  for  indiges- 
tion; and  to  this  the  reader  may  return,  and  peruse  it, 
and  reperuse  it  with  advantage. 

Then  as  to  drinks.  Alcohol  is  undesirable  except  in 
limited  quantities.  Alcohol  is  a  powerful  stimulant  to  the 
liver.  AYhen  taken  fasting,  it  often  produces  an  amount 
of  heat  out  of  proportion  to  that  evolved  in  its  combustion. 


28G  LIVER  DISTURBANCE.  [chap.  xn. 

It  seems  to  liberate  so  much  of  the  liver-glycogen,  by 
dilating  the  branches  of  the  hepatic  artery;  and  so  con- 
verting so  much  glycogen  into  grape-sugar.  When  this 
is  carried  beyond  a  certain  amount,  then  the  vascularity 
of  the  liver  is  increased,  and  it  becomes  enlarged  in  size; 
subsequent  contraction  follows,  with  ascites  and  dropsy  in 
its  wake.  It  is  then  to  be  taken  sparingly.  A  little  claret, 
Carlowitz,  Graves,  or  hock,  may  be  taken  by  those  who 
feel  that  some  such  beverage  is  required  to  enable  them 
to  eat,  and  enjoy  their  food.  Others  find  a  little  simple 
spirit,  as  brandy  or  whisky,  in  plain  or  aerated  water, 
agree  best  with  them.  Potent  wines,  and  all  malt  liquors, 
are  to  be  avoided. 

Aerated  waters  alone,  or  with  a  little  milk,  or  some 
syrup  are  also  indicated.  If  also  alkaline,  it  is  well  not 
to  take  them  during  gastric  digestion  at  least. 

Beyond  the  dietetic  and  medicinal  treatment  of  condi- 
tions of  hepatic  derangement,  lie  the  matters  of  change  of 
air,  and  mineral  springs.'  It  may  be  laid  down  as  an  axiom 
that  "  bilious  persons  are  always  worse  in  a  low-lying,  and 
warm  locality;  and  are  the  better  for  being  in  a  fairly 
bracing  atmosphere."  For  instance,  to  take  London,  such 
persons  are  never  well  in  the  basin  of  the  Thames,  and  are 
always  improved  by  getting  to  the  hills  that  skirt  the  val- 
ley. In  Brixton  tliey  feel  good  for  nothing,  and  are  always 
ailing.  On  the  slopes  of  Hampstead  and  Highgate  they 
are  comparatively  well;  or  on  the  Surrey  hills  around 
the  Crystal  Palace.  This  illustration  will  serve  for  other 
neighbourhoods.  The  oxidising  processes  are  much  favoured 
by  a  bracing  locality.      Consequently,  they  should  not  re- 


CHAP,  xn.]  LIVER  DISTURBANCE.  287 

turn  to  India,  or  the  tropics  if  there  be  any  reason  to  sup- 
pose that  the  secreting  structures  of  the  liver  have  received 
a;iy  permanent  damage.  A  liver  which  may  suffice,  with 
care,  to  carry  on  its  function  in  Great  Britain  may  be  quite 
unfit  for  a  life  in  India.  The  injury  inflicted  upon  the 
liver  by  one  residence  in  India,  the  West  Indies,  Guiana, 
or  Guinea,  incapacitates  the  organ  for  another  such  ex- 
perience; wliich,  therefore,  should  not  be  adventured.  And 
whatever  applies  to  a  liver  unaltered  in  size,  and  free  from 
any  mutilation  of  structure,  as  that  caused  by  an  abscess, 
applies  even  more  stringently  to  a  liver  which  has  been 
crippled  by  disease.  To  speak  broadly  then,  in  hepatic 
derangement  it  is  well  to  avoid  warm,  damp,  low-lying 
localities,  either  as  temporary  or  jDermanent  residences: 
unless  it  be  when  an  east  wind  is  blowing.  This  disturb- 
ing element  upsets  all  ordinary  calculations;  and  when  in 
action  must  be  allowed  for.  Consequently  in  summer  the 
east  coast  is  to  be  preferred  to  the  south  or  west.  Again, 
Ilfracombe  is  to  be  selected  rather  than  Torquay  orDawlish. 
The  AYelsh  resorts  must  be  classed  by  the  same  rule;  and 
so  must  all  others  over  the  face  of  the  globe.  For  such  as 
are  fortunate  enough  to  be  able  to  afford  it,  it  would  be 
well  to  chano^e  their  residence  in  winter  and  summer. 

Then  as  regards  watering-places,  the  same  rule  will 
obtain,  viz.,  a  bracing  locality,  except  when  the  east' wind 
is  blowing.  Sulphur  springs,  with  a  laxative  in  the  water, 
suit  biliousness;  alkaline  waters  are  adapted  for  the  treat- 
ment of  lithiasis.  But  periodical  excursions  to  such  water- 
ing-places must  not  be  made  an  excuse  for  indulgence  in 
the  interval;  as  is  the  case  with  ordinary  individuals.    The 


288  LIVER  DISTURBANCE.  [chap.  xn. 

patients  "with  a  liver"  will  soon  find  that  this  is  a  prac- 
tice not  adapted  to  their  individual  requirements;  nor 
calculated  to  improve  their  condition.  Abstinence  and 
self-denial  must  rule  them  in  their  every-day  walk  in  life. 
But  all  are  human,  and,  as  such,  liable  to  err — to  slip  on 
the  narrow  path;  and  if  a  family  festival,  or  an  important 
celebration  should  lead  to  some  departure  from  the  beaten 
track,  a  mercurial  pill  and  mineral  laxative  are  permis- 
sible; but  they  should  be  resorted  to  with  a  distinct  sense 
of  failing,  of  weakness,  like  the  conviction  of  sin  ex- 
perienced by  a  penitent  at  the  altar. 

When  at  the  sea-side  it  is  not  advisable  for  persons  who 
suffer  from  any  form  of  hepatic  derangement,  to  bathe  much 
in  the  sea;  especially  in  the  early  morning.  The  "dip" 
should  be  brief  and  far  short  of  any  chill.  It  should  be  taken 
about  11  a.ra.,  and  be  followed  by  a  walk.  The  warm  bath 
followed  by  an  hour  or  two  in  bed  to  keep  up  the  action  of 
the  skin,  is  a  measure  which  has  much  to  be  said  for  it; 
and  ao-rees  with  many  verv  well. 

But  each  case  requires  its  own  management  adapted  to 
the  patient's  wants,  requirements  and  exigencies.  The 
attempt  has  here  been  made  to  describe  the  digestive  act  in 
the  alimentary  canal  first,  and  then  after  that  the  function 
of  the  liver;  to  give  the  readers  the  broad  lines  upon  which 
to  proceed.  Sometimes  the  track  is  clear  and  distinct; 
sometimes  broken  and  iixlistinct,  despite  the  light  which 
advancing  physiology  is  throwing  upon  it.  The  liver  is  the 
largest  of  all  glands — has  a  function  proportioned  to  its 
size.  Up  to  a  recent  period  we  knew  nothing  of  its  func- 
tions, except  the  production  of  bile.   Now,  however,  we  re- 


CHAP,  xn.]  LIVER  DISTURBANCE.  289 

cognise  that  it  possesses  a  most  important  action  on  the  one 
hand — (1)  upon  the  further  elaboration  of  the  crude  pro- 
ducts of  digestion  in  the  alimentary  canal;  and,  on  the 
other  hand,  (2)  upon  the  destructive  metamorphosis  of  al- 
buminoids. It  is  then  intimately  related  on  one  side  -with 
indigestion  and  mal-assimilation;  and  on  the  other  with 
lithiasis,'or  gout  in  its  widest  sense.  Its  relations  with  the 
first  have  been  given:  in  Part  11.  I  will  strive  to  describe 
its  relations  with  the  second;  and,  therewith,  the  disturb- 
ances and  diseases  to  which  such  lithiasis  gives  rise  in  its 
turn. 

The  fat  of  our  food  does  not,  as  do  sugar  and  albumin- 
oids, pass  into  the  venules  of  the  portal  vein,  and  thence  to 
the  liver;  but  is  taken  up  by  the  lacteals.  The  liver,  then, 
takes  no  part  in  the  assimilation  of  fats;  except  that  its 
bile  aids  in  the  emulsionising  of  fat  in  the  upper  bowel. 

(While  these  sheets  have  been  passing  though  the  press, 

a  copy  of    "Observations   on    the   Constitutional   Origin 

and  Treatment  of  Local  Diseases,"  by  the   famous  John 

Abernethy,   F.R.S.,   dated  1809,  has   been  lent  me  by  a 

patient,    who   was    re-arranging  his  library;  and  coming 

upon   the   volume,  opened   it,  read  some  of  it,  and  was 

struck  by  what  was  written    there,  as  being  almost  the 

very  remarks  made  by  myself  about  his  regimen.     It  is 

gratifying  to  find  myself  in  accord  with  so  capable  a  man. 

Medicine  has  forgotten  a  good  deal,  as  well  as  learnt  much 

this  century  !) 
13 


APPENDIX. 


THE  FAILURE  OF  THE  DIGESTIVE  ORGANS  AT  THE 
PRESENT  TIME. 

The  perusal  of  the  foregoing  chapters  will  have  shown  the 
reader  that  there  actually  exists,  or  at  least  1  hold  there 
exists,  a  strong  tendency  to  failure  in  the  organic  processes 
at  the  present  day.  These  organic  processes  furnish  the 
elaborated  pabulum  for  the  organs  of  active  life: — albumen 
for  the  tissues  generally,  haemoglobin  for  the  red  blood  cor- 
puscles, and  lecithin  for  the  nervous  system.  The  tre- 
mendous demands  made  upon  the  nervous  system  at  the 
present  time  is  believed,  by  others  as  well  as  myself,  to  be 
the  cause  of  this  failure.  The  effects  of  mental  worry,  and 
emotion  upon  the  digestive  and  secretory  functions  is  given 
in  Chap,  vi.,  pp.  85-106.  The  increased  demand  upon  the 
nervous  system,  and  especially  the  cerebral  hemispheres 
in  the  present  day,  is  telling  upon  the  whole  of  the  digestive 
organs,  and  especially  upon  the  liver;  which  carries  on  the 
further  elaboration  of  the  crude  products  of  digestion  in 
the  alimentary  canal.  As  we  saw,  glycogen  is  stored  by 
the  dehydration  of  the  grape  sugar  in  the  portal  vein;  and 
from  these  stores  regular  rations  are  given  off  by  hydration, 
under  the  action  of  the  liver  ferment,  to  the  blood  for  the 
production  of  body  heat  and  force.  Then  the  liver  not 
only  elaborates  the  products  of  the  gastro-intestinal  diges- 
tion of  proteids,  but  it  is  the  furnace  in  which  e£Pete,  waste, 


Ai'PENDix.]  THE  DIGESTIVE  OROAKS.  291 


and  surplus  albuminoids  are  burnt.     The  bile  aids  the  pan- 
creatic secretion  in  the  emulsifying  of  fats. 

Now  it  was  abundantly  shewn  that  mental  states  pro- 
foundly modify  these  processes,  as  temporary  conditions. 
Not  only  that;  but  there  is  much  pointing  in  the  direction 
that  the  pace  at  which  we  live  nowadays,  is  exercising  a 
persisting  effect  upon  the  digestive  organs,  of  a  deteriorat- 
ing character.  The  dental  caries,  so  prevalent,  indeed 
universal  at  the  present  day,  is  but  a  part  of  the  general 
widespread  failure  of  the  digestive  organs.  Our  grand- 
parents hardly  ever  heard  the  word  "  dentist,"  but  the 
present  generation  know  him  well;  and  if  they  do  not 
regard  him  with  affection,  at  least  recognise  his  utility. 
The  increase  in  the  demand  for  laxative  medicines  is  de- 
monstrated by  the  perpetual  advertisements  which  meet 
the  eye,  from  natural  waters,  through  an  almost  endless 
series,  to  Holloway's  pills.  Constipation  is  not  claimed 
to  be  a  modern  malady;  what  is  asserted  is,  that  it  is  on 
the  increase.  Up  to  the  days  of  our  parents,  children  had 
porridge  and  milk  for  breakfast,  took  them  well,  digested 
them  (for  "porridge"  always  requires  the  plural  with  it),  and 
throve  on  them.  The  American  on  the  boundless  prairie  is 
"  raised  upon  hominy,"  and  in  his  physique  is  a  contrast  to 
the  product  of  the  Eastern  states — the  advantage  not  lying 
with  the  New  Englander.  The  diastase  of  the  cerealia  has 
only  of  late  years  been  pressed  into  the  service  of  man,  to 
supplement  the  failure  in  the  natural  diastase  of  the  sali- 
vary secretion.  Our  predecessors  know  as  little  of  diastase 
and  its  functions,  practically,  as  did  the  chemist,  scientifi- 
cally.    Pepsin  derived  from  animals,  or  even  a  plant — the 


292  FAILURE  OF  [appendix. 

papua,  is  also  of  recent  date.  The  pancreatic  secretion, 
scientifically  and  practically,  is  a  matter  strictly  of  our 
own  times. 

Whence  comes  the  profound  modification  of  the  organic 
processes,  the  commissariat  of  the  active  or  animal  part  of 
the  body  ?  It  is  the  effect  of  modern  demand  upon  the 
nervous  system,  it  is  believed  ;  and  not  w^ithout  a  good 
amount  of  evidence  for  the  belief.  We  know  that  the 
body  is  influenced  in  the  direction  of  deterioration  by 
subtle  forces.  The  inability  of  the  Ano-lo-Saxon  to  in- 
habit  India  is  a  well-recognised  fact.  The  children  of 
Anglo-Saxon  parents,  born  and  reared  in  India,  deteri- 
orate so  markedly,  that  it  is  now  quite  usual  to  send  the 
Younfr  Ano'lo-Indian  to  Europe  to  be  reared  and  educated. 
It  is  said  that  in  the  third  generation  the  Anglo-Indian 
dies.  Be  this  the  exact  truth,  or  only  an  approach  to  it, 
ii'  is  a  fact  of  or-rim  sio;nificance. 

The  same  fatality  has  been  found  to  attach  itself  to  the 
aborigines  of  large  towns.  It  appears  that  without  regular 
and  repeated  infusions  of  new  blood  by  incomers  from  the 
country,  the  town- dweller  would  perish  off  the  face  of  the 
earth.  A  deterioration  is  wrought  by  a  protracted  resi- 
dence in  a  large  town.  What  said  Lugol,  the  great  French 
authority,  about  the  inhabitants  of  Paris  : — "  Scrofula 
shews  itself  in  the  third  generation  of  those  whose  an- 
cestors entered  Paris  full  of  health  and  vigour,  and  from 
the  third  generation  the  malady  rages  even  to  the  utter 
extermination  of  the  family  name."  This  is  a  very  frank 
statement,  without  reserve,  by  an  eminent  authority;  and 
its  frankness  is  quite  equalled  by  its  gravity.  *^  To  the 
utter  extinction  of  the  family  name,"  i.e.,  to  complete  ex- 


APPENDIX.]  THE  DIGESTIVE   ORGANS.  293 

termination.  From  this  it  would  seem  town-dwellers  are 
a  doomed  race. 

The  population  of  towns  is  now  in  excess  of  the  country 
in  Great  Britain.  The  food  of  town-dwellers  is  inferior  to 
that  of  the  jjeasant  population;  as  all  familiar  with  the 
subject  only  know  too  well.  The  revelations  of  the  Fac- 
tory Commission,  amidst  the  toilino-  millions  of  our  manu- 
facturing-  towns,  especially  those  where  spinning  mills  are 
common,  are  as  instructive  as  they  are  appalling.  The 
evidence  of  Dr.  Ferguson  of  Bolton,  before  the  Commis- 
sion, told  a  terrible  tale  as  to  the  infant  mortality,  and  the 
deterioration  of  the  physique  of  the  young  mill-hands  when 
appearing  to  be  certified  for  work  in  the  mills.  Dwarfing 
was  on  the  increase  in  spite  of  the  Factory  iVcts.  (x\nd 
the  improvement  which  resulted  from  these  beneficent 
Acts,  is  readily  admitted  by  those  who  knew  the  mill- 
districts  on  each  side  of  the  slopes  of  the  back-bone  of 
England,  before  and  after  the  passing  of  these  Acts.)  One 
bright  spot  alone  was  visible  amidst  the  darkness  and  the 
gloom,  and  that  was  the  good  effects  of  a  certain  amount 
of  milk  in  the  dietary,  in  the  improvement  of  the  physique. 
Those  w^ho  feel  interested  in  this  matter  can  consult  TJie 
Sanitary  Record  for  July  17th  and  Sept.  25th,  1875. 

A.  dietary  of  tea  and  bread  and  butter,  was  much  im- 
proved when  a  certain  amount  of  milk  w^as  added  to  it. 
Now  the  steady  increase  of  the  population  of  towns  is  a 
fact;  that  the  increase  will  go  on  further  and  further  is 
as  certain  as  that  to-morrow's  sun  will  rise.  The  subject 
is  one  of  the  gravest  importance  to  us  ;  of  even  graver 
importance  to  succeeding  generations.  Of  course,  for  the 
toiling  millions  little  can  be  done  beyond  the  building  of 


294  FAILURE   OF  [appendix. 

airy  and  comparatively  healthy  suburbs,  and  the  estab- 
lishment of  workmen's  trains,  night  and  morning,  into 
the  larger  towns;  and  the  inculcation  of  broad  principles 
about  food  and  drink,  fresh  air,  pure-water,  and  effective 
drainage.     The  poor  have  a  hard  lot  indeed  ! 

But  for  those  whose  means  permit  of  their  consulting 
the  health  of  their  little  ones,  something  more  may  profit- 
ably be  said.  Unpalatable  much  of  what  is  to  be  written 
will  be  to  many.  Impossible  perhaps  to  a  few.  But  as 
children  ovi^e  a  duty  to  joarents  ;  so  parents  owe  a  duty  to 
those  children  whom  they  call  into  being.  The  State  now 
takes  care  that  the  children  shall  have  at  least  the  rudi- 
ments of  an  education;  it  protects  them  from  small-pox 
by  compulsory  vaccination,  one  of  the  most  beneficent  of 
all  discoveries.  It  guards  their  dietary  by  the  Food  Adul- 
teration Act.  Then  milk  is  brought  in  tins  from  the 
mountain  pastures  of  Switzerland,  in  unlimited  quantities; 
about  the  purity  of  "which  no  doubt  can  reasonably  be  en- 
tertained. The  fat-containing  maize  is  brought  to  us  in 
numerous  forms.  There  is  no  difficulty  in  providing  milk 
and  a  farinaceous  dietary  for  our  town  infants.  Much  can 
be  done  for  them;  but  more  must  be  done  still.  Artificial 
digestive  agents  may  be  given  with  suitable  food,  to  aid 
in,  and  perfect  the  natural  digestion.  But  something  more 
is  desirable. 

For  our  animals,  and  more  especially  valuable  stock  like 
racehorses,  breeding  stations  in  healthy  localities  are  pro- 
vided. Surely  the  offspring  of  cultured  human  beings  are  as 
valuable,  and  worthy  of  as  much  care  as  the  descendants  of 
"  Stockwell,"  and  of  "  West  Australian !  "  Something  simi- 
lar is  desirable  in  the  shape  of  institutions,  placed  in  suitable 


APPENDIX.]  THE  DIGESTIVE  ORGAN'S.  295 

localities  and  under  proper  supervision;  where  town-born 
children  could  be  received  in  tender  years,  and  reared. 
Plenty  of  exercise,  in  the  open  air,  would  secure  an  appe- 
tite for  simple  food,  as  well  as  the  perfect  oxidation  of  all 
waste  matter;  and  the  child  placed  under  such  favourable 
circumstances,  would  be  as  free  from  deterioration  as  is 
the  racehorse.  For,  thoug-h  much  has  been  said  about  the 
deterioration  of  the  racehorse,  it  does  not  appear  that  any 
falling  off  actually  exists.  Certainly  the  practice  of  train- 
ins;  them  so  earlv.  as  is  now  the  fashion,  is  not  o-ood  for 
these  immature  scions  of  a  noble  race;  but  from  personal 
enquiries  made  of  Mr.  John  Day,  the  well-known  trainer 
at  Danebury,  and  his  neighbour,  Mr.  Tom  Cannon,  the 
equally  well-known  jockey  and  trainer,  no  falling  off  is 
discernible  in  the  racing  stock  of  the  present.  Indeed,  in 
the  opinion  of  the  latter  authority,  the  young  stock  of  the 
present  is  actually  an  improvement  upon  anything  Avhich 
has  preceded  it.  This  came  out  casually  during  an  en- 
quiry into  the  feeding  of  racehorses,  and  their  training; 
which  is  very  severe  and  trying.  One  of  the  greatest 
sources  of  anxiety  to  the  trainer  is  the  failure  of  the  ap- 
petite. This  entails  the  suspension  of  the  training.  It 
was  said  before,  at  (p.  101),  that  the  use  of  tonics  and 
bitters  is  not  unknown  amonsf  the  trainino-  establishments 
for  racehorses;  but  in  neither  of  these  Hampshire  train- 
ing stables  are  these  adjuvants  adopted.  Indeed,  in 
Mr.  Cannon's  opinion,  simple  loss  of  appetite  in  a  healthy 
young  racehorse,  never  occurs;  he  holds  that  when  the 
young  horse  is  "off  his  feed,"  it  indicates  son^ething 
wrong  with  it  elsewhere.  The  air  of  these  Hampshire 
downs    is    very  bracjng,    anc^  whets  the    appetite    of  the 


296  FAILURE  OF  [appendix. 


human  beings  as  well  as  racehorses  who  reside  on,  or  near 
them. 

My  enquiries  were  directed  to  the  matter  of  any  possible 
failure  of  the  digestive  organs  in  the  racehorses  of  the 
present  due  to  the  excitement  and  mental  tension  of  their 
mode  of  life.  This  may  seem  somewhat  whimsical  to 
some  readers;  but  the  racehorse,  I  am  credibly  informed 
in  the  absence  of  any  personal  knowledge,  lives  a  life  of 
much  excitement  and  full  of  incident.  Some  enjoy  the 
race;  others  dislike  and  dread  the  event,  or,  to  use  the 
precise  expression  for  it  for  which  we  have  no  equivalent 
in  ordinary  English,  "  funk  "  immensely  when  being  got 
ready  for  the  race.  It  seemed,  therefore,  desirable,  in 
order  to  make  my  observations  on  the  matter  of  the  ner- 
vous relations  of  indigestion  as  complete  as  possible,  to 
extend  my  enquiry  to  animals  whose  existence  entails 
much  demand  upon  the  nervous  system;  as  the  life  of 
a  racehorse  undoubtedly  does.  The  results  of  my  en- 
quiries were  strictly  negative;  at  least  as  regards  these 
Hampshire  training  stables.  But  there  is  much  analogy 
betwixt  the  existence  of  racehorses  and  human  beings. 
Especially  young  racehorses,  run  as  they  now  are  so 
largelv  at  two  and  three  years  old.  It  seemed  quite 
possible,  that  this  early  training  and  nervous  tension 
might  affect  the  young  horse;  just  as  life  in  a  large 
town  affects  human  infants  in  the  way  of  failure  of  the 
digestive  organs.  But  so  far  there  is  no  evidence  of  any 
such  cause  and  effect;  and  this  I  am  inclined  to  attri- 
bute to  the  fact,  of  young  racehorses  being  reared  in  the 
country,  in  the  healthiest  localities  that  can  be  seciir^d  for 
the  purpose. 


APPENDIX.]  THE  DIGESTIVE  ORGANS,  297 

When  we  consider  the  life  of  children  of  the  present 
day  in  large  towns,  we  become  painfully  aware  of  the 
truth  underlying  the  old  adage: — "You  cannot  both  cat 
your  cake  and  have  your  cake."  The  town-child  is  pro- 
vided with  innumerable  and  many  very  elaborate  complex 
toys  in  its  nursery.  It  is  constantly  carried  to  sights 
which  will  please  it,  and,  in  doing  so,  excite  it.  Its  little 
life  is  a  round  of  gaiety,  so  far  as  its  indulgent  parents 
can  manage  it.  It  is  taken  to  the  circus,  to  the  pan- 
tomime; it  has  its  children's  parties  and  balls;  it  is  edu- 
cated to  mimic  the  life  of  pleasure.  Heaven  save  the 
mark  !  of  its  seniors.  Everything  to  "  force  "  its  bram  is 
aggregated.  And  a  forced  product  it  is,  in  its  precocity  ! 
But  precocity,  the  late  Prof.  Lay  cock  held  to  be  an  unde- 
sirable matter,  as  incompatible  with  a  full  and  complete 
development  in  the  adult;  and  those  who  have  paid  atten- 
tion to  the  matter  agree  with  him.  The  little  infant  of 
the  Lemuridce,  a  lowly  form  of  monkey,  will  follow  its 
mother  the  day  it  is  born;  but  it  is  only  a  Lemur  when  its 
full  potentiality  is  realised. 

The  little  Baboon  baby  rolls  on  its  back,  and  gazes  at 
its  extremities  in  perplexity  and  wonder  for  about  a  month 
before  it  commences  its  perigrinations;  but  it  develops  into 
an  anthropoid  ape  ultimately,  capable  of  much  that  is  im- 
possible to  the  Lemur.  The  human  baby  passes  through 
a  longer  and  more  protracted  period  of  helplessness,  but 
it  possesses  the  potentialities  of  a  man  in  it;  and  may  de- 
velop into  an  engineer  who  can  span  a  river,  throw  an  iron 
girdle  over  an  estuary;  or  an  astronomer  who  can  weigh 
the  stars  in  his  balance,  and  calculate  the  perturbations  of 

the  planets,  or  the  erratic  path  of  a  comet. 
13* 


298  FAILURE   OF  [appendix. 

Early  development  is  not  to  be  desired,  and  the  forced 
products  of  town  life  can  no  more  last  well,  than  does  the 
racehorse  raced  long  before  his  period  of  growth  is  com- 
pleted. The  promising  two-year  old,  and  the  quick-witted 
town-child,  neither  possess  much  prospect  for  their  later 
3^ears.  The  comparatively  dull,  stupid,  heavy  country 
child  has  a  far  brighter  future  before  it.  It  is  keeping  its 
cake,  not  eating  it.  It  is  building  up  a  stalwart  frame;  its 
brain  is  comparatively  inert  ^' lying  fallow;"  its  energies 
are  not  expended  in  a  round  of  variety  and  excitement;  it 
is  slowly  developing  its  utmost  potentialities,  not  being 
exhausted  prematurely.  This  is  an  aspect  of  the  subject 
which  cannot  be  overlooked  in  any  scheme  for  the  im- 
provement of  future  generations.  Lugol  found  struma 
grovr  up  in  town-bred  children;  and  what  is  struma  but  an 
impaired  protoplasmic  digestion,  a  tissue  deterioration  ? 
Such  children  if  born  of  country  people  and  reared  in  the 
country  would  have  been  free  from  any  such  tissue  degen- 
eration. ^ 

This  subject  is  one  which  has  long  engaged  my  atten- 
tion, and  in  November,  1877,  I  delivered  a  lecture  before 
"  The  London  School- Mistresses'  Association''''  upon  "The 
Relations  of  Growth  to  Education  "  which  was  subsequently 
republished  by  them  as  a  pamphlet.  More  recently  the 
matter  has  been  fully  considered  in  a  pamphlet  "The 
Physiologist  in  the  Household,"  Part  L,  Adolescence  (pub- 
lished by  Bailliere,  Tindal  &  Cox,  1880);  which  I  venture 
to  believe  is  worth  perusal  by  those  specially  interested  in 
this  subject.  Oliver  Wendell  Holmes  in  his  quaint,  pithy 
way  alludes  to  this  subject  in  his  "  Autocrat  at  the  Break- 
fast Table."     He  writes — "Men  often  remind  one  of  pears 


APPENDIX,]  THE  DIGESTIVE  ORGANS.  299 


in  tlieir  "vvay  of  coming  to  maturity.  Some  are  ripe  at 
twenty,  like  human  jargonelles,  and  must  be  made  the 
most  of,  for  their  day  is  soon  over.  Some  come  into  their 
perfect  condition  late,  like  the  autumn  kinds,  and  these 
last  better  than  the  summer  fruit;  and  some  like  the  win- 
ter helis,  have  been  hard  and  uninviting  until  all  the  rest 
have  had  their  season,  get  their  glow  and  perfume  long 
after  the  frost  and  snow  have  done  their  worst  with  the 
orchards.  Beware  of  rash  criticisms  ;  the  rough  and 
stringent  fruit  you  condemn  may  be  an  autumn  or  a 
winter  pear;  and  that  you  picked  up  beneath  the  same 
bougrh  in  Auo-ust,  niav  have  been  onlv  its  worm-eaten 
windfalls.  Milton  was  a  Saint-Germain  with  a  graft  of 
the  roseate  Early-Catharine.  Rich,  juicy,  lively,  frag-rant, 
russet-skinned  old  Chaucer,  was  an  Easter-Beurre;  the 
buds  of  a  new  summer  were  swelling  when  he  ri]3ened." 

This  is  rather  wandering  from  the  exact  subject  matter, 
— pursuing  a  side-issue  in  legal  phraseology,  but  it  bears 
on  what  is  being  discussed  here,  viz.,  the  development  of 
a  healthy  physique,  endowing  its  possessor  with  greater 
potentialities  in  the  future.  The  child  reared  in  the 
country  has  a  brisker  appetite  and  a  better  digestion 
than  the  town-child.  If  his  o-pow-th  is  slower,  he  ulti- 
mately  attains  a  larger  stature.  Quetelet  '*'  Sur  I'Homme  " 
proved  this  about  the  physical  stature;  it  is  equally  true 
about  the  mental  and  intellectual  stature.  How  far  im- 
perfect digestion  and  assimilation  is  the  cause  of  the  ar- 
rested development,  either  wholly  or  in  part,  may  scarcely 
be  apportioned ;  but  it  is  a  factor,  be^'ond  question. 
Girls  develop  more  rapidly  than  boys;  but  their  ulti- 
mate development  is  less   than  that  of  boys.      This  side- 


300  FAILURE  OF  [A^PE^^)IX. 

issue  is  intimately  linked  with  the  exact  raatter  under 
discussion,  viz.,  the  rearing  of  town  bred-and-born  chil- 
dren in  the  countiy. 

Of  course  the  objection  will  be  raised,  that  it  is  impos- 
sible to  send  the  children  awav.  Well  !  The  Ang-lo-Indian 
has  to  do  it.  And  there  is  no  evidence  that  Ano-lo-Indians 
are  wanting  in  family  affection,  only  they  have  learned  to 
subordinate  their  own  feelings  to  their  children's  welfare. 
And  the  town-resident  at  home,  not  in  Great  Britain  alone, 
but  wherever  the  Anglo-Saxon  has  raised  his  tent-pole 
over  the  face  of  the  earth,  must  learn  to  do  likewise. 
The  ghost  of  the  Red  Indian  flitting  around  the  old 
burying  places,  and  dreaming  of  the  old  wigwam  stand- 
ing where  a  huge  town  now  exists,  has  the  sinister  con- 
solation of  thinkino-  that  the  white  man  cannot  live  on 
the  land  he  has  usurped — without  special  precautions. 
The  red  man's  grave  is  covered  with  the  white  man's 
buildings,  solid,  massive,  immense  ;  but  his  first-born 
die  in  them.  Colonel  Pyncheon  erected  "  The  House 
of  the  Seven  Gables,"  where  Matthew  Maule  had  built 
his  rude  hut,  "shaggy  with  thatch;"  but  a  Kemesis 
hunof  around  the  land  snatched  from  the  murdered  man. 
"  God  !  "  said  the  poor  man,  on  his  way  to  the  scaffold, 
innocent  of  the  crime  of  witchcraft  for  which  he  was  con- 
demned to  die, — ''  God  Avill  give  him  blood  to  drink." 

So  ma}'  say  the  ghost  of  the  red  man  of  the  present 
possessor  of  his  land,  too.  The  Anglo-Saxon  has  ex- 
terminated the  Red  Indian,  "  Thou  shalt  want  ere  I 
want "  has  been  his  creed.  The  waning  Indian  had  to 
vacate  his  possessions  for  the  Yengees,  that  they  might 
increase  and  multiply  on  the  face  of  tlie  earth.      And  now 


APPENDIX.]         THE  DIGESTIVE  ORGANS.  301 

what  is  the  result?  The  Anglo-Saxon  is  a  dying  race, 
perishing  beside  the  tomb  of  the  red-man  whom  he  slew. 
It  is  "  Naboth's  vineyard,"  in  the  nineteenth  century  ! 

What  if  this  grim  and  terrible  fact  be  an  undoubted  fact: 
and  it  seems  that  the  threatened  extinction  of  the  old 
population,  so  immediate  for  Massachusetts,  is  being  in- 
augurated in  Ohio.  The  nutrition  of  the  American-born 
woman  is  often  unequal  to  feeding  a  second  organism;  or 
if  that  second  organism  has  successfully  struggled  into  an 
independent  existence,  it  is  unequal  to  its  maintenance 
for  long.  The  spectre  of  the  exterminated  Red  man  sees 
death  reaping  a  rich  harvest  among  the  babes  and  suck- 
lings of  his  enemy;  there  are  other  graves  being  dug 
alongside  those  of  his  ancestors.  The  angel  of  death  is 
smiting  the  usurper  in  turn.  If  this  be  so,  the  American 
has  the  sorry  consolation  of  knowing  that  in  his  old  home, 
in  tlie  cradle  of  his  race,  the  same  phenomenon  is  to  be 
observed;  only  not  yet  to  so  distinct  and  terrible  an  ex- 
tent. The  Anglo-Saxon  exterminated  the  native  British; 
there  was  no  compromise;  the  conquered  Briton  did  not 
become  "  a  hewer  of  wood  and  a  drawer  of  water  " — the 
serf  of  his  victorious  assailant;  he  perished,  died  out  abso- 
lutely. The  Anglo-Saxon  settled  down  on  the  vacated 
lands  and  increased  and  multiplied.  For  generations  this 
process  went  on,  successful  and  unchecked.  Dirt,  filth, 
the  disregard  of  all  hygienic  laws,  the  neglect  of  the  sani- 
tary arrangements  of  old  Roman  civilization;  the  crowd- 
ing, the  narrow  tenements;  indeed,  the  necessity  for 
regarding  a  town  as  a  fortress  in  the  interminable  wars 
of  the  dark  ages,  and  erecting  the  houses  accordingly — 
brought  plagues  in  their  wake;  often  exterminating  the  in- 


302  FAILURE  OF  [appendix. 

habitants,  and  causing  the  markets  to  be  held  in  the  open 
country  at  some  distance.  Now  the  scene  is  changed,  but 
not  the  venue.  Where  the  wattled  huts  of  the  ancient 
Briton  once  stood,  amidst  sacred  groves  devoted  to  Druid- 
ical  rites;  now  we  see  the  many-storied  mill,  the  long 
chimney  belching  forth  smoke,  the  endless  rows  of  cottages 
inhabited  by  the  toilers  who  work  in  the  mill.  The  Angel 
of  death  i^  busy  still.  With  the  practical  turn  of  his  race 
the  town-inhabitant  protects  himself  and  his  young,  so  far 
as  lies  in  his  power;  brings  his  water  from  long  distances, 
constructs  elaborate  sewerag-e  arrangements,  thus  copying 
the  wisdom  of  the  old  heathen  at  last;  further,  he  has 
appointed  Medical  Officers  of  Health  and  Analysts,  still 
more  to  guard  him  and  his.  He  has  learned  that  poison- 
germs  may  lurk  in  his  water,  and  still  more  in  his  milk- 
supply,  since  Dr.  M.  W.  Taylor,  of  Penrith,  first  pointed 
out  the  danger  hidden  in  the  milk-can  (1858);  and  re- 
peated outbreaks  of  scarlatina,  following  the  milk-supply, 
have  driven  the  lesson  home.  He  has  provided  so  far  as 
in  his  power  lies,  against  these  fluid-borne  diseases:  and 
the  tale  of  the  dead  so  slain  is  but  as  a  unit  against 
myriads.  For  one  victim  to  zymotic  disease,  a  holocaust 
perish  from  failure  in  their  digestive  processes.  For  one 
infant  lying  in  its  last  sleep  from  specific  germ-carried 
pyrexia,  a  thousand  wasted  marasmatic  atomies  are  to  be 
found  in  their  graves  from  improper  food,  and  an  imper- 
fect digestion. 

It  is  time  then  that  some  general  united  effort  be  made 
to  arrest  this  slaughter  of  the  Innocents;  compared  to 
which  Herod's  massacre  was  as  nothing.  It  may  be 
costly;  it   may    entail   many  sacrifices;   the    parent    may 


APPENDIX.]         THE  DIGESTIVE  ORGANS.  303 

liave  to  consent  to  separation  from  the  child;  children 
may  have  to  grow  up  no  longer  under  the  parent's  eye, 
except  at  intermittent  periods;  but  under  the  skilled 
supervision  of  guardians  bound  to  them  by  no  tie  of 
blood.  All  this  may  be  very  repulsive;  but  unfortunately 
it  is  unavoidable  !  Some  such  practice,  which  will  enable 
children  to  be  reared  in  the  country,  must  be  adopted  be- 
fore long.  Food  of  the  most  digestible  character  may  be 
supplemented  by  artificial  digestive  agents;  but  this  is 
only  palliative  as  regards  the  individual, — it  is  not  cura- 
tive as  regards  the  race  ! 

The  town-population  in  Great  Britain  now  constitutes 
the  majority  of  the  people.  The  issue  is  a  sharp  one:  and 
must  ere  long  occupy  the  attention  of  our  legislators. 
But  it  is  to  be  feared  that  any  such  action  must  be  pre^ 
ceded  by  much  outside  discussion  of  the  question.  How, 
and  by  what  precise  measures  the  evil  has  to  be  met,  and, 
if  possible,  vanquished,  it  is  not  for  me  to  say  here.  First 
the  evil  must  be  fully  appraised  before  adequate  measures 
for  dealing  with  it  can  be  formulated.  My  duty  extends 
to  pointing  out  the  actual  facts,  and  indicating  the  direc- 
tion the  proposed  measures  must  take;  to  go  further  would 
savour  of  impertinence,  and  overweening  vanity.  The 
actual  solution  of  the  problem  will  engage  many  minds, 
and  exercise  many  intellects,  before  "Eureka"  can  be 
shouted. 

In  order,  however,  to  grapple  with  the  difficulty  in  a 
practical  form,  and  to  do  what  can  be  done,  until  such 
arrangements  can  actually  be  made  for  the  rearing  of 
town-children  in  the  country,  I  give  some  valuable  re- 
marks by  Prof.  L.  Duncan  Bulkley,  M.D.,  of  New  York, 


304  FAILURE  OF  [appendix. 

the  wearer  of  an  honoured  name.  Dr.  Bulkley  and  myself 
discussed  most  earnestly  the  question  of  the  coming  race — 
if  there  is  to  be  one  at  all — on  the  banks  of  the  Cam,  at 
the  Annual  Meeting  of  the  British  Medical  Association, 
1880;  and  now  by  his  courtesy,  I  am  enabled  to  lay  before 
the  reader  what  he  has  found  desirable  in.  the  interests  of 
the  children  in  the  U.  S.  A.;  whose  necessities  are  indeed 
greater  than  ours. 


''ON    THE    FAILURE   OF   NUTRITION  IN  CHILDREN, 
WITH  ITS  TREATMENT,  BY  DR.  BULKLEY. 

The  nutrition  of  the  body  is  dependent  on  very  many  dif- 
ferent factors,  all  of  which  must  be  perfect  to  constitute 
perfect  health.  Nutrition  in  children  has  to  do  with  two 
quite  different  elements ;  first  the  growth  of  the  body,  and 
second  the  repair  of  waste.  Failure  in  nutrition  to  a 
greater  or  less  extent  must  involve  defect  in  one,  or  both  of 
these  respects;  when  the  growth  of  the  body  is  interfered 
with,  the  actions  of  life  are  deranged.  Failure  in  nutrition 
in  children  has  two  great  causes,  which  are  hereditary  or 
acquired.  Far  too  much  stress  has  ordinarily  been  placed 
upon  the  former,  which,  of  course,  is  irremediable; 
whereas  the  latter,  upon  which  in  reality  the  greatest 
measure  of  the  difficulty  rests,  is  quite  amenable  to 
careful  and  judicious  treatment.  We  will  first,  therefore, 
briefly  dismiss  the  former,  or  hereditary  causes  of  failure  of 
nutrition,  in  order  to  devote  more  thought  to  the  second  or 
acquired  causes,  upon  whose  proper  recognition  and  under- 
standing must  rest  much  of  success  in  medical  practice. 


APPENDIX.]         NUTRITION  ly  CfflLDFEy.  305 


In  regard  to  hereditary  causes  of  imperfect  nutrition  in 
children,  all  cases  may  be  divided  into  three  great  sub- 
divisions; first,  those  exhibiting  the  influence  of  the  stru- 
mous habit;  second,  those  showing  the  gouty;  and  third, 
those  characterised  by  the  nervous  temperament  or  habit. 
There  can  be  no  doubt  that  as  children  manifest  to  a 
greater  or  less  extent  certain  physical  peculiarities  of  form 
and  feature,  and  also  certain  mental  idiosyncrasies;  and 
as  certain  diseases,  as  syphilis,  can  undoubtedly  be  trans- 
mitted to  offspring;  and  certain  conditions  of  system,  or 
tendencies  thereto,  such  as  phthisis,  gout,  rheumatism, 
and  cancer,  can  likewise  be  transmitted;  that  the  less  pro- 
nounced states  of  physical  constitution  can  in  like  manner 
be  handed  down,  so  that  the  individual  with  the  strumous, 
gouty,  or  nervous  habit  or  condition,  transmits  the  same 
even  to  the  child  at  its  youngest  period  of  life.  Thus  we 
may  have  developed  and  exhibited  in  the  infant  these 
stages  to  a  greater  or  less  degree,  and  they  may  act  as 
sufficient  causes  in  modifvino^  its  nutrition. 

AVe  therefore  see  a  certain  number  of  infants,  or  very 
small  children,  exhibiting  signs  of  imperfect  nutrition, 
which  are  intimately  dependent  upon  the  state  or  habit  of 
body  which  they  have  acquired  with  birth.  The  strumous 
child  speaks  plainly  by  its  light  delicate  hair,  its  pasty- 
white  complexion,  and  its  enlarged  lymphatic  glands  and 
flabby  muscles  ;  either  with  very  light  or  very  dark  eyes, 
long  eyelashes,  large  nose,  thick  upper  lip;  and  if  skin 
lesions  form  they  will  be  characterised  by  the  develop- 
ment of  pus  and  a  tendency  to  the  formation  of  thick  scabs, 
or  crusts,  not  accounted  for  by  the  intensity  of  the  inflam- 


306  FAILURE  OF  [appendix. 

mation.  Its.  failure  of  nutrition  Avill  be  exhibited  rather 
by  the  great  appetite,  decayed  teeth,  swollen  abdomen, 
often  filled  with  wind;  tendency  to  constipation  and  in- 
testinal worms.  The  gouty  child  will  show  a  tendency  to 
an  acid  stomach,  as  an  infant  will  often  vomit  milk,  will 
have  occasional  attacks  of  constipation,  alternating  with 
diarrhoea.  Will  very  frequently  be  restless  at  night  as  a 
result  of  its  indigestion;  and  if  skin  lesions  manifest  them- 
selves they  will  be  characterized  rather  by  a  redness  of 
surface,  great  itching,  tendency  to  watery  exudation,  dry- 
ing into  thinner  scales  or  crusts,  with  much  less  tendency 
to  pus  formation.  The  child  with  the  nervous  habit  or 
temperament  will  show  its  failure  of  nutrition  by  an  ir- 
regular and  fitful  appetite,  and  easily  deranged  digestion, 
especially  interfered  with  by  nerve  causes,  as  over-excite- 
ment, &c.  It  will  be  wakeful  rather  than  restless  at  night, 
and  irritable  during  the  day. 

These  states,  or  conditions  which  belong  more  or  less 
markedly  to  infantile  cases,  are  important  to  recognise. 
And  there  is  undoubtedly  no  little  truth  in  the  old  idea, 
in  regard  to  the  family  physician  understanding  the  con- 
stitution of  the  patient;  and  this  is  especially  true  with 
regard  to  children.  But  if  a  reasonable  amount  of  care 
and  judicious  thought  be  given  to  the  cases,  these  features 
may  be  understood  and  developed  by  one  who  has  but 
recently  met  the  person  affected.  And  success  in  practice 
depends  to  a  very  large  measure  upon  the  grasp  which  the 
physician  takes  upon  the  idea  as  to  the  constitution,  or 
state  of  the  child  he  is  to  treat. 

But  if  the  knowledge  and  appreciation  of  these  features 
are  valuable  in  the  treatment  of  disease,  or  the  restoration 


APPENDIX.]         NUTRITION  IN  CHILDREN.  307 

to  health  of  tliose  suffering  from  imperfect  nutrition;  a 
perfect  comprehension  of  the  elements  next  to  be  con- 
sidered is,  if  possible,  yet  more  important.  For  the  fea- 
tures which  have  been  dwelt  upon  belong  so  completely  to 
the  constitution  or  state  of  the  individual,  that  frequently 
they  cannot  be  altered  to  any  very  great  extent  by  the  phy- 
sician; whereas  the  elements  relating  to  the  daily  life  of 
the  patient,  next  to  be  treated  of,  are  such  as  the  physician 
can  affect;  and  upon  his  proper  management  of  them,  will 
rest,  to  a  large  degree,  the  success. 

We  come  therefore  to  the  second,  or  most  important  ele- 
ment, or  factor  of  failure  of  nutrition  in  children,  namely, 
the  acquired  causes  of  its  beginning,  and  continuance. 

There  is  no  one  who  has  even  the  slightest  knowledge 
of  botany  but  recognizes  that  the  plant-life  is  different, 
not  only  in  various  sections  of  the  earth,  but  in  different 
portions  of  the  same  tract  of  territory,  according  to  the 
relations  existing.  Not  only  is  there  the  vast  difference 
between  the  products  of  the  earth,  of  temperate  and  tropi- 
cal climates;  but  in  the  temperate  zone  we  find  the  great- 
est varieties  in  nature,  according  to  the  soil,  situation, 
moisture,  and  sunlight,  &c.  We  would  never  expect  to 
find  the  lily  of  the  valley,  or  wood  violet  on  the  top  of  a 
mountain,  nor  the  mountain  shrub  pine  in  the  depths  of 
the  valley.  Certain  plants  absolutely  require  a  certain 
soil;  if  they  are  placed  in  any  other,  they  wither  and  die. 
One  will  require  a  great  amount  of  moisture;  others  but 
little,  or  none.  The  same  is  true  of  the  animal  creation; 
one  animal  thrives  upon  food  on  which  another  would 
perish.     Therefore,  upon  the  proper  selection  and  adminis- 


308  FAILURE  OF  [appendix. 

tration  of  food,  or  the  proper  regulation  of  the  hygiene  and 
surroundings  of  the  patient,  depends  the  measure  of  health 
which  it  is  to  enjoy.  The  cause  of  failure  of  nutrition  in 
children,  in  by  far  the  larger  proportion  of  instances,  has 
to  do  Avith  external  factors  rather  than  with  hereditary 
states.  The  diet  and  hygiene  of  the  child  require  to  be 
regulated  with  the  utmost  nicety,  if  we  would  secure  per- 
fect nutrition.'  Even  as  a  hot-house  in  which  delicate 
plants  are  being  reared,  requires  careful  skill  and  thought; 
ignorance  in  one  will  be  followed  by  evil  results,  quite  as 
surely  as  ignorance  in  the  management  of  the  other. 

Instinct  is  undoubtedly  given  to  living  beings  for  the 
purpose  of  the  preservation  of  the  species  :  and  when 
allowed  to  operate  undisturbed  may  be  very  largely  and 
safely  relied  upon.  In  the  lower  animals  instinct  un- 
doubtedly is  all  sufficient  for  the  maintenance  of  perfect 
nutrition  in  the  young  as  well  as  in  the  adult  ;  provided 
that  other  causes  do  not  operate  in  too  great  a  degree. 
But  animals  and  birds  can  readily  be  made  sick  by 
temptations  offered  to  them  in  the  way  of  food;  also  by 
deprivation  of  air,  light,  etc.  The  natural  instinct  of  the 
young  infant  is  for  milk;  and  upon  proper  milk  it  thrives. 
Older  children  are  quite  satisfied  with  very  simple  food, 
provided  they  are  not  attracted  by  other  things.  It  must 
be  remembered,  however,  that  instinct  cannot  be  trusted  to 
entirely  in  children  because  of  the  many  perturbations  to 
which  life  is  subject,  and  of  the  many  temptation^  which 
appear  on  all  sides  to  transgress  the  rules  of  health.  The 
child  is  then  dependent  upon  the  intelligence  and  knowledge 
of  those  older  than  itself;  and  it  certainly  does  not  answer 
to  allow  the  tastes  of  the  infant,  or  child,  to  be  the  guide  in 


APPENDIX.]         NUTRITION  IN  CHILDREN.  309 

the  matter  of  diet  and  hygiene.  On  unsuitable  food,  given 
in  an  improper  manner  perfect  nutrition  certainly  will 
not  be  maintained.  And  for  the  perfect  development  of 
the  child,  care  and  thought  should  be  exercised  by  its 
guardians. 

As  failure  in  nutrition  may  be  due  to  improper  food,  so 
it  may  also  be  due  to  imperfectly  prepared  food.  Coming 
now  to  the  actual  facts,  the  food  which  the  infant  feeds 
upon,  the  mother's  milk,  may  often  be  greatly  impaired  in 
its  quality;  and  where  there  is  failure  of  nutrition  in  the 
infant  child  at  the  breast,  this  should  always  be  looked  to. 
In  nursing  infants  with  eczema  it  will  constantly  be  found, 
that  the  health  of  the  mother  is  not  perfect;  and  a  careful 
investigation  will  always  find  elements  to  be  corrected  in 
it.  It  is  very  common  to  find  that  the  mother  is  in  the 
habit  of  consuming  large  quantities  of  tea,  or  perhaps  beer, 
or  ale,  or  takes  wine  pretty  freely;  or  perhaps  she  is  taking 
strong  chocolate,  or  milk  in  order  to  promote  lactation,  and 
these  disagree  with  her,  causing  dyspepsia.  Or  she  is 
constipated,  or  in  her  urine  she  has  disorders  indicative  of 
derang-ement  of  dio^estion  and  assimilation.  Now  if  these 
elements  exist,  if  the  mother's  secretions  as  from  the 
bowels,  kidneys,  skin,  liver,  etc.,  are  not  healthy,  certainly 
the  secretion  of  milk  is  not  healthy;  and  thus  it  cannot 
afford  the  proper  nutriment  for  the  child.  In  the  case  of 
nursing  infants,  therefore,  exhibiting  the  signs  of  failure  of 
nutrition,  the  attention  should  always  be  turned  first  to- 
wards the  mother.  And  in  a  very  large  percentage  of 
cases,  errors  of  assimilation  and  integration  will  be  found 
in  the  mother,  w^hich  must  be  corrected  before  we  can  hope 
for,  or  expect  great  and  permanent  benefit  to  the  child.    It 


310  FAILURE  OF  [appendix. 

must  never  be  forgotten  that  the  mother  may  have  exten- 
sive oxaluria,  as  ahnost  the  sole  indication  of  mal-assimi- 
lation;  or  she  may  have  simply  a  coated  tongue,  acid  taste 
in  the  mouth,  or  other  signs.  Or  she  may  have  a  general 
tired  feeling,  especially  in  the  morning  after  sleep.  The 
nursing  mother  should  not  be  allowed,  as  a  rule,  to  take 
fermented  liquors;  and  generally  the  quantity  drank  should 
be  diminished  especially  if  it  is  used  in  excess.  Milk  an- 
swers best  in  the  large  proportion  of  instances  for  the 
mother;  and  if  it  is  not  well  borne  at  first,  the  habit  of 
taking  it  can  be  acquired;  very  frequently  it  is  necessary 
to  add  a  little  alkali,  and  the  liqua:  potassse  10  or  15  ms. 
may  be  added  to  each  tumbler-full  of  milk. 

In  not  a  few  instances  the  milk  furnished  by  the  mother 
is  absolutely  too  weak  to  sustain  the  child  properly;  and 
the  mother's  health  must  be  improved  by  such  tonics  as 
iron,  bark,  cod-liver  oil,  etc. 

The  nursing  child  with  mal-nutrition  may  also  be  bene- 
fitted by  the  exhibition  of  certain  remedies;  although  in 
the  main  the  proper  supply  of  milk,  with  sun-light  and 
fresh  air,  and  absence  of  nervous  excitement,  will  gene- 
rally be  all-sufficient.  Constipation  is  a  far  more  common 
state  even  in  infants,  than  is  usually  supposed;  and  many 
will  be  found  who  are  dependent  for  their  daily  action  of 
the  bowels  upon  enemata,  or  suppositories  of  soap,  etc. 
The  occasional  administration  of  a  proper  dose  of  calomel, 
will  in  some  cases  be  of  the  very  greatest  service  in  pro- 
moting the  nutrition  of  infants.  This  of  course  should  not 
be  persisted  in  to  any  great  extent;  but  occasionally  it 
may  be  given  with  advantage  as  often  as  every  few  days. 
Pepsin,  or  lacto-peptine  may  be  used  with  very  great  ad- 


APPENDIX.]         NUTRITION  m  CHILDREN.  311 

vantage  at  times  in  even  very  small  infants,  exhibiting 
imperfect  nutrition;  either  a  little  placed  dry  on  the 
tongue,  or  held  in  suspension  in  flour-water,  or  the  like, 
taken  at  each  time  of  nursing. 

In  many  instances,  especially  in  strumous  children,  cod- 
liver  oil  will  be  found  to  be  of  the  greatest  service,  even  in 
very  small  infants;  although,  their  power  of  digestion  of 
fats  being  small,  it  should  be  given  in  very  small  quanti- 
ties, and  not  too  often.  It  may  sometimes  be  used  with 
great  advantage  in  the  way  of  inunction;  and  linseed  oil, 
or  sweet  almond  oil  may  be  substituted  for  this  purpose. 

Again,  very  many  children,  especially  those  of  a  "  gouty 
stock  "  will  have  their  nutrition  very  greatly  benefited  by 
the  administration  of  a  small  quantity  of  alkali;  for  this 
purpose,  perhaps,  lime-water  answers  very  well,  having  the 
additional  advantage  of  supplying  the  elements  necessary 
for  the  growth  of  the  bones.  But  sometimes  this  is  distaste- 
ful, and  sometimes  it  seems  to  fail;  we  may  then  use  the 
liquor  potassas  with  advantage.  Enquiry  should  always  be 
made  in  regard  to  the  urine  of  these  little  ones,  and  if  it  is 
found  to  stain  the  diaper  much,  an  alkali  should  be  used, 
with  remedies  calculated  to  act  upon  the  kidneys.  For 
this  purpose  the  following  prescription  will  often  be  found 
of  very  great  value. 

^.  Potassse  Acetatis  3i.— 3ii. 

Spiritus  JEther.  Nitrosi  3  i. —  3  ii. 
Liquor  Ammon.  Acetatis   |  ii. 

A  teaspoonful  three  or  four  times  daily,  near  the  time 
of  nursino-. 

If  there  is  much  restlessness  at  night,  and  any  tendency 


312  FAILURE  OF  [appendix. 

to  feverishness,  a  little  aconite  may  be  added  to  this  mix- 
ture with  great  advantage. 

Many  infants  receive,  in  addition  to  the  parent's  milk, 
or  perhaps  in  place  of  it,  diet  which  is  entirely  erroneous. 
A  number  of  infants  suffering  from  imperfect  nutrition 
are  found  to  be  taking  large  quantities  of  starchy  food,  such 
as  corn-starch,  bran,  etc.;  and,  in  many  instances,  far  too 
much  sugar  is  given  with  the  food.  Sometimes,  however, 
there  are  very  great  errors  committed  with  regard  to  the 
diet  of  these  little  ones;  and  one  finds  constantly  among 
the  poor  classes  of  children  of  the  most  tender  years,  those 
who  are  allowed  to  partake  of  anything  eaten  b}^  adults,  for 
which  they  may  crave.  And  it  is  not  at  all  uncommon  to 
find  children,  even  less  than  a  year  old,  who  are  allowed  to 
partake  of  tea,  and  coffee  perhaps,  even  more  than  once  a 
day.  And  one  may  often  see  in  the  hands  of  very  small 
children  the  most  indigestible  substances,  to  say  nothing 
of  crackers,  candy,  etc.  It  would  seem  almost,  at  first  sight, 
as  though  these  errors  could  not  prevail  among  the  upper 
classes,  but  we  have  only  to  remember  that  the  nurses,  to 
whom  so  much  is  often  committed,  all  come  from  the  lower 
ignorant  classes;  and  unless  they  are  watched  and  directed 
otherwise,  they  will  tend  to  practice  just  what  they  have 
been  brought  up  to,  and  taught  at  home. 

One  sees  a  great  many  children  in  whom  imperfect  nu- 
trition has  resulted  from  the  continuance  of  nursing  long 
after  the  suitable  period  has  passed,  or  after  the  mother 
has  ceased  to  secrete  milk  which  is  properly  nutritious. 
The  manner  in  which  little  infants  so  impoverished  will 
pick  up,  when  placed  upon  proper  and  suitable  nutriment, 


APPENDIX.]         NUTRITION  IN  CHILDREN.  313 

is  sometinies  amazinc:.  The  greatest  benefit  mav  be  often 
derived  from  the  addition  of  the  yolk  of  an  egg  once  or 
twice  daily  to  the  diet  of  very  small  children;  this  may  be 
given  either  raw  or  lightly  cooked,  mingled  with  the  milk, 
or  taken  separately. 

After  children  have  passed  from  the  breast,  there  is 
danger  of  ver}''  great  errors  being  committed  in  regard  to 
the  nutrition  of  the  child.  Far  too  often  it  is  allowed  to 
select  its  own  food  indiscriminately  from  that  used  by 
adults.  And  even  if  it  does  not  fail  in  securing  the  ele- 
ments required  for  the  formation  of  its  frame,  it  will  very 
commonly  be  found  that  it  has  induced  an  indigestion 
•which  may  be  kept  up  by  the  same  means;  and  thus  have 
its  nutrition  materially  impaired.  The  weak,  strumous, 
irritable  child  therefore,  should  have  its  diet  looked  to,  and 
directed  with  even  greater  care  than  its  lactation.  Injuri- 
ous articles  must  be  absolutely  interdicted  with  a  firm  hand ; 
and  the  proper  nutriment  for  the  case  must  be  insisted 
upon,  at  all  hazards.  Some  of  the  elements  of  "indigestion, 
biliousness,  or  gout  in  its  protean  aspects,"  may  be  very 
commonly  discovered ;  ultimately  to  be  developed  elsewhere. 
These  must  be  diligently  sought  for  and  remedied.  It  is 
useless,  when  called  upon  to  improve  the  condition  of  a 
growing  child,  simply  to  give  this  or  that  remedy ;  either 
one  which  has  been  recommended  by  some  one  or  another, 
or  one  which  has  been  found  serviceable  in  what  seems 
a  similar  case.  These  cases  cannot  be  treated  upon  a 
written  plan.  The  habit,  or  constitution  of  the  child  must 
be  investigated;  its  diet  and  mode  of  life,  powers  of  sleep 
and  bathing,  and  also  anything  which  can  conduce  in  any 
14 


314  FAILURE  OF  [appendix. 

way  to  its  health,  must  come  under  the  scrutiny  of  the 
physician. 

When  the  child  arrives  at  somewhat  older  years,  the 
elements  of  schooling,  and  its  intercourse  with  others,  must 
be  taken  very  carefully  into  consideration.  Every  child 
cannot  be  submitted  to  the  same  routine  of  life;  every 
child  cannot  bear  the  same  amount  of  schooling,  or  even  of 
home  instruction.  Nor  can  every  child  be  allowed  the  free 
exercise  of  its  will  in  regard  to  its  exercise,  and  many  other 
matters  of  life;  just  as  all  adults,  or  even  animals,  can- 
not be  submitted  to  the  same  work,  confinement,  nervous 
strain,  etc.,  and  yet  maintain  health. 

Far  too  little  attention  has  been  paid  in  past  and  recent 
times  to  the  value  of  milk  as  a  nutrient.  This  can  be 
advantageously  added  to  the  diet  of  very  many  individuals 
— even  of  adults;  and  it  can  even  be  taken  in  the  intervals 
between  the  meals,  or  made  to  supplem.ent  them.  Should 
it  cause  any  of  the  elements  recognised  under  the  general 
term  of  "biliousness,"  this  tendency  may  be  more  or  less 
averted  by  the  administration  of  an  alkali  at  the  same  time, 
together  with  care  in  the  regulation  of  the  bowels,  etc.,  etc. 

We  have  thus  seen  that  failure  of  nutrition  in  children 
in  a  large  number  of  instances,  is  not  always  one  and  the 
same,  depending  upon  identical  causes;  but  that  there  are 
many  elements  connected  with  it,  each  one  of  which  may 
be  of  more  or  less  importance  in  individual  cases.  And 
as  the  chain  is  only  strong  in  the  perfect  integrity  of  each 
and  every  link,  so  health  is  only  maintained  at  a  perfect 
standard  by  the  integrity  of  action  of  every  organ;  and  ti\e 
proper  supply  of  nutriment  for  the  growth  and  repair  of 
each  portion  of  the  body.    The  hereditary  tendency  of  the 


APPENDIX.]       miTRiTiOjsr  m  children:  315 

child,  must  be  to  a  greater  or  less  extent  recognised  in 
each  instance  therapeutically;  and  the  main  general  line 
of  treatment  must  be  more  or  less  altered  in  accord  there- 
with. But  by  far  the  largest  share  of  causation  of  the 
failure  of  nutrition,  is  to  be  found  in  the  surroundings  of 
every  day  life;  and  only  by  careful  study  and  acquaintance 
with  these,  can  a  case  be  guided  into  health. 

Internal  medication  can  undoubtedly  do  a  great  deal  to 
improve  nutrition  even  in  the  youngest  subjects;  but  it 
must  be  ever  remembered  that  the  action  of  the  medicant 
is,  and  will  be  but  temporary;  while  the  erroneous  diet  or 
mode  of  life  may  go  on  long  after  the  patient  has  ceased 
to  take  medicine.  And  as  treatment  cannot  restore  the 
patient  to  more  than  the  condition  of  perfect  health  pre- 
viously enjoyed;  so  when  the  diseased  state  is  removed, 
there  will  be  naturally  the  tendency  to  return  to  it,  if  the 
same  causes  are  continually  at  work,  and  in  operation. 

In  addition  to  the  cod-liver  oil  so  commonly  required 
by  strumous  children,  and  the  alkalies  of  service  in  the 
gouty  state,  we  will  find  very  great  improvement  in  many 
instances  from  the  use  of  arsenic.     And  when  combined 
with  iron,  it  forms  one  of  the  most  powerful  means  of 
restoring  nutrition  and  vitality.     The  following  combina- 
tion will  be  found  of  great  service  in  many  instances. 
1^   Liquor  Potassse  Arsenitis,  3  ss. —  3  i. 
Ferri  Ammon.  Cit.,   3  ss. —  3  i. 
Potassse  Citrat,   3  i- —  3  ii. 
Vini  Ferri  Dulcis  (Malaga),   J  iii. 

Teaspoonful  after  eating. 

The  syrup  of  the  lacto-phosphate  of  lime  is  often  very 
valuable  in  improving  the  nutrition  of  children,  as  also  the 


316  NUTRITIOIT  IN  CHILDREN.        [appendix. 

syrup  of  the  phosphates  of  lime,  soda,  and  iron.  Care 
must  always  be  exercised,  however,  in  administering  these 
tonics,  that  the  action  of  the  bowels  be  as  perfect  as  pos- 
sible, and  that  the  kidneys  do  their  work.  Many  cases 
will  be  found,  where  iron,  cod-liver  oil,  and  various  tonics 
have  been  previously  employed  without  effect,  in  which 
success  was  attained  rapidly  after  very  moderate  attention 
to  the  emunctory  organs  of  the  body. 

The  condition  of  the  skin  as  an  organ,  should  never  be 
forgotten  in  connection  with  failure  of  nutrition  in  chil- 
dren. It  is  not  very  common  that  they  are  bathed  too 
little,  although  this  sometimes  occurs.  Probably  they  are 
more  often  bathed  too  frequently;  and  perhaps  are  too 
often  chilled  in  the  bath  or  afterwards,  and  the  repulsion 
of  the  blood  from  the  surface  may  result  in  internal  dis- 
orders. 

Cold  hands  and  feet  are  a  very  frequent  indication  of 
imperfect  nutrition  in  children.  These  should  be  attended 
to;  the  children  should  not  be  allowed  to  go  to  bed  with 
icy  feet,  which  will  often  be  the  means  of  causing  wakeful- 
ness for  some  lenofth  of  time  aftei*  retirins;-. 

The  feet  should  be  warmed  either  artificially  by  putting 
them  in  hot  water,  or  by  w^arm  applications  to  them,  and 
wearing  of  socks.  Or  if  there  is  sufficient  vigour,  a  reac- 
tion may  be  obtained  by  a  quick  plunge  into  cold  water. 
Cold  hands  and  feet  are  always  an  evidence  of  imperfect 
circulation;  and  this  of  itself  does  most  frequently  cause 
an  indigestion.  When  the  hands  and  feet  are  cold,  the 
bath  should  be  used  in  moderation. 

FINIS. 


IXDEX. 


Page 

A  ction  of  Saliva      .         .        ■    .   9 
Action  of  Stomach,  Imper- 
fect Solvent     .         .       .     24 
Actual  Treatment  of  Children  .  305 
Acute  Indigestion        .         .        .  128 
in   Typhoid 

Fever 130 

Affections  of  the  Skin         .        .  230 
Albuminoids,  Digestion  of  .     13 

"  Effects  of  Cooking  on  46 
Albuminuria  .  .  .  .319 
"  Sir  Joseph  Fayrer  on  219 
Alcohol  ....  143,  285 
Angina  Pectoris  ....  227 
Apex-Consolidation  of  Lung  .  132 
Appetite,  Natural  Failure  of  the  254 
Artificial  Digestion  .  .  .55 
Artificial  Digestive  Ferments     .     41 

Asthma 225 

Attack,  Bilious   .         .         .         .167 
Attention,  Influence  of  Expec- 
tant        102 

Azoturia 215 

"one,  Effects  of  Dieb  upon        .  172 
Bile,  Effects  of,  upon  the 
Heart       ....  195 

Bile,  Effects  of,  upon  the  Xer- 
Tous  System  .        .         .  196 

Bilious  Attack    ....  167 

Biliousness 167 

"  Chronic  .  .  .174 
"  Effects  on  the  Mind  .  191 
"  Symptoms  of  .  .182 
"        Treatment  of       .         .  178 


Page 
Bladder  SjTnptoms  .  .  .  228 
Brain    and    Digestive     Organs, 

Reiations  of    ,     .         .         .  105 
Brunton,  Dr.  Lauder,  Views  of .  163 


/~>ancer.  Gastric 
Caries,  Dental 


29 

291 

117 

50 

29 


Cardiac  Indigestion 

Caseine  of  Milk  . 

Catarrh,  Gastric 

Cause   of  Indigestion,    S3'philis 

as  a 123 

Causes,  Mental,  of  Diabetes,      .     94 
"  "        of  Indigestion  .     86 

Causes  of  Decay  in  Children        .  292 
"  Derangement    of    the 

Liver     .        .        .  233 
"  Diabetes      .         .       18,  94 

Children,  Diseases  of,  Treatment 

of  Actual      ....  305 
Children,    Diseases   of.    Preven- 
tive         293 

Children,  Types  of      .         .         .  306 
Climates,  Hepatic  Unfitness  for 

Hot 25~^ 

Clinical  Relations  of  Uric  Acid    211 
Colour  of  Tongue        .         .         .182 

"         Urates         .         .         .214 
Confident    Expectation,   Effects 

of 106 

Congenital  Insufficiency  of  the 

Liver 241 

Congestion   of  the  Liver,   Uric 

Acid  in 213 


318 


INDEX, 


Page 
Consolidation  of  Lung  Apex      .  132 
Cooking,  Effects  of,  on  Albumi- 
noids    .         .         .         .         .46 
Cooking,  Effects  of,  on  Fat        .     51 
'^  "  Starch  .     43 


TPv  ecay  in  children,  Causes  of  .  290 
-^  Dehydration  ...  17 
Derangement      of     the     Liver, 


Causes  of      ...         . 

233 

Diabetes      .         .         .         .       18,  94 

"        Mental  Causes  of 

94 

Diarrhoea     .         .         .        .   •      . 

30 

Diastase 

42 

Diet 

136 

"    Effects  of,  upon  Bile  . 

172 

Dietary  in  Indigestion 

i;;9 

Digebtion,  Intestinal  . 

17 

"          Natural      . 

7 

"          of  Albuminoids 

13 

*'           "  Fat         .        .         . 

15 

"           "  Starch    . 

8 

Digestive  Artificial  Ferments     . 

41 

"        Organs  and  Brain,  Re- 

lations of 

105 

"        Power,  Failure  of 

290 

"            "        Variety  of       . 

244 

Dilatation,  Gastric      . 

30 

Disintegration     .... 

11 

"             Imperfect    . 

21 

Disorder,   Functional,  of  Liver, 

Treatment  of         .         .         . 

280 

Disturbances  in  the  Heart . 

226 

"        Phenomena  of  Liver 

167 

Disturbance,    Treatment    of 

Liver-  

249 

Drinks 

141 

"      Iced  .         . 

14 

"      Temperance 

143 

Dr.  Kirkes'  Views 

151 

Dr.  Lauder  Brunton's  Views 

163 

Dr.  Murchison,  Views  of    . 

154 

Fag-e 
"Epffect  of  Bile  upon  the  Heart .  195 
-^  ''            "            "       Mind.  191 
"        Nerv- 
ous System  .         .  196 
*'        Confident  Expectation  106 
"        Cooking   on    Albumi- 
noids      46 

Effect  of  Cooking  on  Fats         .     51 

Starch  .     43 

"        East  Winds        .        .  200 

Emigrant  Life     ....  135 

Examine  Urine,  Time  to     .        .  209 

Expectant  Attention,  Influence 

of 1C2 


TT'ailure  of  Digestive  Organs     .  290 
Failure,  Natural,  of  the  Ap- 
petite       ....  2.54 

Fat,  Digestion  of        .        .       15,  59 
"     Effects  of  Cooking  on  .         .51 

Fayrer,  Sir  Joseph,  on  Albumin- 
uria        219 

Ferments 8 

"        Artificial  Digestive     .     41 

Fever,  Indigestion  in  Typhoid  .  130 

Faeces 9 

Food,  Peptonised        .        .        .63 
Salt  as       .         .         .         .19 

Fulness,  Venous,  of  Liver  .         .  237 

Functional   Disorder    of    the 

Liver,  Treatment  of     .        .  280 

Function  of  Pancreatic  Secretion    17 
the  Liver.        .         .  148 
"  "  Dr.  Brun- 

ton's  Views  ....  163 

Function    of     the     Liver,    Dr. 

Kirkes'  Views  of  .         .         .  151 

Function  of  the  Liver,  Dr.  Mur- 

chison's  Views  of  .         .  154 

Furred  Tongue    .         .        .         .33 


f^  astric  Cancer 


VJT 


Catarrh 


29 

29 


INBEX. 


319 


Gastric  Dilatation 
"■         Irritability 
"^        Stimulants 
*'        Ulcer       . 


Page 

.  30 

.  31 

.  26 

.  29 


TTaemoglobin    .        .         .        .15 
-^^     Headache  ....     38 
Heart,  Disturbance  in         .         .  226 
"        Effects  of  Bile  upon         .  195 
"        Starvation        .         .         .80 
Hepatic  Unfitness  for   Hot  Cli- 
mates   .         ,         .        .        .  255 
Hereditary  Impairment   of    the 

Liver 246 

Hydration 12 

Hydrogen,  Sulphuretted     .        .  193 

Teed  Drinks       .         .        .         .142 

Impairment,    Hereditary,    of 

the  Liver      .         .         .        .246 

Imperfect  Digestion    .         .         .21 

''  Solvent  Action  .         .     24 

Indigestion,  Acute,      .         .         .  128 

Cardiac  .         .         .117 

"  Dietary  in      .        .  139 

"  Heart  Hypertrophy  133 

"  in  Emigrant  Life    .  lo5 

"  in  Lung  Apex  Con- 

sol'dation     .        .  132 
"  Intercurrent   .         .  126 

"  in  Typhoid  Fever   .  130 

"  Liver       .         .         .203 

"  Xeurosal  .         .     85 

*'  Ovarian.         .         .  110 

"  Reflex     .         .        .109 

*'  Secondary       .         .     85 

"  Symptoms  of  .     34 

"  "  Mental    40 

*'  Syphilis  as  a  Cause 

of         .        .         .  123 
"  Toxemic         .        .  123 

Influence,  Nervous      .         .         ,  239 
*'         of  Expectant  Atten- 
tion        .        .        .102 


Page 

Irritability,  Gastric    .         .         .31 
Insufficiency,  Congenital,  of  the 

Liver 241 

Intestinal  Digestion    .         .        .17 


"T  ecithin    . 

Life,  Emigrant 


20,  76 
.  135 
.     61 


Liquor,  Pancreaticus 

Liver,     Causes  of   Derangement 

of  .  .  .  .233 
' '        Congenital  Insufficiency 

of  the.  .  .  .  241 
"        Disturbance,  Treatment 

of  .  .  .  .  fi49 
"        Functional  Disorder  of 

the  .  .  .  .  167 
"  Functions  of  the  .  .  148 
"        Impairment,  Hereditary, 

of  the  .         .         .  246 

"  Indigestion  .  .  .  203 
'*  IS'ervous  Influence  on  .  239 
"  Stimulants  ...  28 
"  Treatment  of  .  .  280 
"        Uric  Acid  in  Congestion 

of  the  .         .        .  213 

"        Yenous,  Fulness  of        .  237 

^X/Tastication      .         .         .         .48 
'^        Mental  Causes  of  Diabetes    94 
Mental   Symptoms    of    Indiges- 
tion         40 

Mercar}',  Use  of  ...  250 

Metabolisms,  Perversions  of  .  224 
Milk.  Casein e  of  .  .  .  .50 
Murchison,    Dr.,    Vie-ws   on  the 

Functions  of  the  Liv^er         .  151 

"VTatural  Digestion    ...       7 

"^      Is'atural  Failure  of  Appetite  254 

!  Nervous  Influence  on  Liver         .  239 

"        Symptoms     .         .         .230 

"        System,  Effects  of  Bile 

upon  .         .         .  196 

Neurosal  Indigestion  .  .  .85 
Nutrition  Tissue  .         .        .70 


320 


INDEX. 


/^varian  Indigestion 
^  Oysters 


Page 

.  110 
.     44 


"TDancreaticus  Liquor  .  .  61 
Pancreatic  Secretion,  Func- 
tion of  .  .  .  .17 
Pancreatic  Stimulants  .  .  27 
Pectoris,  Angina  .  .  .  227 
Pepsin.        .....    58 

Peptones 18 

Peptonised  Food  .  .  .63 
Perversions  of  Metabolism  .  224 
Phenomena  of  Liver  Disturb- 
ance .....  167 
Potash,  Utility  of  .  .  .  203 
Preventive  Treatment  of  Degen- 
eration   292 

Production  of  Uric  Acid    .         .  205 
Proteids 56 


TDeflex  Indigestion  . 

Relations  of  Brain  and  Di- 
gestive Organs 


Qaliva,  Action  of 

Salivary  Stimulants 

Salt  as  Food 

Secondary  Indigestion 

Skin  Affections    . 

Sleeplessness 

Solvent  Action,  Imperfect . 

Starch,  Digestion  of  . 

"       Effects  of  Cooking  on 


109 
.  105 

.   9 

.  25 
.  19 
.  85 
.  230 
.  197 
.  24 
.  10 
.  43 


Starvation,  Heart 

.     80 

Stimulants,  Gastric     . 

.    26 

"             Liver 

.     28 

"             Pancreatic 

.    27 

Struma 

.     72,  298 

Sulphuretted  Hydrogen 

.  193 

Pag:e 

Symptoms  of  Biliousness    .        .183 
"  Bladder      .         .         .  228 

"  of  Indigestion    .         .     34 

"  Mental,    of    Indiges- 

tion        .        .         .40 
"  Nervous     .        .        .230 

Syphilis  as  a  Cause  of  Indiges- 
tion         123 


n^emperance  Drinks 
Tissue  Nutrition  . 


.  143 
.     70 

Tongue,  Colour  of       .         .        .  183 
"        Furred  .  •       .         .         .33 
Toxsemic  Indigestion  .        .        .  123 
Treatment,  Actual,  of  Children  305 
"           of  Liver  Disturbance  249 
"            Preventive,  of  Chil- 
dren        293 

Tubercle      .....     74 
Types  of  Children       .         .         .  306 

TTlcer,  Gastric  .        .         .         .29 

Unfitness,  Hepatic,  for  Hot 

Climates  .         .         .  255 

Urates.  Colour  of         .         .         .  214 

Uric  Acid,  Clinical  Relations  of  211 

"  in  Congestion  of  the 

Liver     .         .         .218 

''  Production  of  .        .  205 

Urine,  Time  to  Examine     .        .  209 

Use  of  Mercury   .         .         .         .250 

XTariety  of  Digestive  Power  .  344 

Venous  Fulness  of  Liver  .  237 

Views  of  Dr.  Lauder  Brunton  .  163 

Dr.  Duncan  Bulkley  .  305 

''       Dr.  Kirkes    .         .  .  151 

"       Dr.  Murchison     .  .  154 


TTTater,  Colour  of 
^^    Wines 


214 
145 


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